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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLIC#T10V <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> AV- ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on bus' ess in the jurisdictional area of the;lan Joaquin Local Health District <br /> Business Name (DBA) J`�i9ti�Z��l JG,1V Address _/ - �' �� -5 9J7 <br /> z Owner Address <br /> C <br /> J Firm Partners, Addresses andLT�lephonecN�umbers <br /> CL Business Telephone No. f�� f Emergency Telephone No. <br /> % 3 <br /> Contractor Licence No. <br /> Applicants Name (Print) L f Title p Date <br /> Please check Applicable Category (1-7)and Fill in the Required In rmation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r,� <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 /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. I1 SANITATION PERMIT <br /> Job Address/Location 2 ,601 72_,�00?ee <br /> Owner /y7/2. 6`17�--J Address <br /> M SEPTIC TANK ❑ CESSPOOL LEACHING FIELD PSI SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER (� <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner orlicensed agent's signature ce.tifie"the foltowing:1rertsf•y�that in thep�rformanceoftheworkforwhichthispermituissued,lshallnotemployanyp r <br /> i;1 such manner as to become suhiect to workman,:,cr r;nen -firn iaa s ct r:aT!for <br /> Contractor's hiring or c�-�nnerscting ai9l ature c n_iy es ,, jcaovji,g 1 cwlify that in the perfornanca of the work for which this permit is issued,I:iha <br /> employ persons sdbiec w ,c ?„la:,�L.,ar cr�:;,�;,,Ia�i-of tti rn�a." <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 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE L4S CJc1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />