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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) �Q 5 c f - N Address 77 } $ J <br /> r ^f Address 7 . L 3 aXT X*At " <br /> a Owner <br /> u Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 7^ S A _ Emergency Telephone No. <br /> -JContractor Licence No. A - _ <br /> Q 1 �. . Sa f <br /> L Applicants Name (Print) Title - <br /> Please check Applicable Category (1-7)-and,fill in the Required;Information_.. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .June 30, 19- Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> i <br /> Capacity' Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <br /> For July 1, ` June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. NO. <br /> Test Location t Test Date/Time <br /> 4. 0 SANITATION PERMIT9zo <br /> l <br /> 77 RA <br /> sS do�L <br /> Job Address/Location ­- F <br /> Owner ,-is Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ]Q� Q <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW D9 REPAIR ❑ OTHER ?r w^� tTGJ <br /> 5. 11 CHEMICAL"TOILETS For July 1,-June 30, 19 1 <br /> Type Construction Disposal Site -- . <br /> No. of Units Equipment Storage/Cleaning Location(s) l< i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 } <br /> Operator Name Where Certified € <br /> e <br /> Plant Location f <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY . For July 1, -June 30, 19-,- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I <br /> t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> komo owner or licensed aonnt's :�w_fottovutnp:"I certify sfr,ti`.,',the pe•'armance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to taa;colmt,subject to wordman't;; mpensatlon taws of Caiiforni:. , <br /> Contractor's Firing or sub-contracting signature z&rtifiee, the following: "i Certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman'6 6oaalpensatien laws of Califefnia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District: <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ZZ � <br /> Fee Is Due: C1ANNUALLY © PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receive By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE. DATE .REMITTED AMOUNT <br /> FEE *S ys i• <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r h <br /> OTHER <br /> a <br /> OTHER <br /> _[Received by ate - Receipt NO. Permit No. - issuance Date Mailed Delivered <br /> R <br /> APPLICANT—RETURN ALL COPIES.+O: ENVIRONIANTAL HEALTH PERMITISERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 5520 <br />