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Applications WIII Be Processed When Submitted Properly Completed.Be Sure To Sign The 4lpplicallon. <br /> APPLICATION <br /> r (For Non-Transteieble,Reroeable,'and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT (/ <br /> LIQUID WASTE <br /> Application is r made toc ZZ <br /> b�Js�nes ' the jurisdictional area of the SanJoaquinLocal H�eallh District <br /> m Business Nammg�BA) !J 9�l Q 1. ress <br /> Owner_y�_ ('J f� /I/L° Address <br /> 3 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. / .Emergency Telephone No. <br /> Contractor Licence No. <br /> ApplicantsName(Print) Title Date y„Z <br /> Please check Applicable Category(1-7)and Fill In the Required Information.• <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - W <br /> For July 1, 0 June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) n <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 t, June 30, 19 , <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored - r-. - <br /> 3. ❑ PERCOLATION TEST _ 1 <br /> R.S.or R.C.E.Name R.S.or R.C.E'No. <br /> Test Location Test Date/Time <br /> 9. SANITATION PERMIT <br /> Job Address/Location1 �y e,46Ct.�GS® <br /> Owner �iuthq Jy yiCaL/w/O!$ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD A2:;$EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> i 5- ❑ CHEMICAL TOILETS For July 1, -June 30,-19. <br /> --e — >oG <br /> -Type Construction Disposal Site fl. <br /> No.of Units Equipment Storage/Cleaning Location(s) (1, <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/Amaunt/Mo. <br /> Home owneroraeenaed epeni'aaigneturo eerlitieethe ieaowinp:"1 eenHyINPI In IheeeABrmemse of the vyork for which this permit is issued.I shall not employ any person <br /> insuch manner as to becoele subject to workmmi;r^Inp!;n:,u rP:f+rr,: <br /> Comrnek«•s hiring or sub ntrecnnp uglu,Iore cenit;.e 1J, toaowing: 1 cortify thei la the performarce ol the work forwhich this permit is issued,I Shall <br /> employ persons subject to workmen's compeamibn laws of taitiornia;' <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 r nd reg tions o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � �,�f. <br /> O - <br /> 1 ' FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE •. 0 EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE �S.�^ti� AMOUNT DUE CHECKED <br /> DATE DATE. 'REMITTED _ «> AMOUNT <br /> FEE ✓fj� S 5 <br /> LESS <br /> PRORATION <br /> + PLUS <br /> PENALTY / <br /> t OTHER <br /> OTHER f7, <br /> 65� (o of y <br /> Received by Daft Receipt No. Per Na. seuance L0 Maned Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITMERVICES tact E.HAZEL E.,P.O.Ilm 20" STOCKTON,CA Men w� <br />