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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 /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) )Q06627" /y�F1L-SO/v - Address 4 5 az -ras�&gg-t4 P-p <br /> aOwner -_ Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. C�J. _rClr� <br /> Contractor Licence No. <br /> a Applicants Name (Print)- -L aI�' t J��/� �'N�r �f�$ V", ate <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 /> 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. 0 PERCOLATION TEST <br /> R.S. or R.C.E. Name " rt'1/V' R.S. or R.C.E. No. Oc? <br /> Test Location Test Date/TimeO�L� ►"'� S7�r-+/T7 f`l2+r9�`� <br /> 4. ❑ SANITATION PERMIT /' M BC3 - t1 <br /> Job Address/Location ` S�� Pc"Ir- <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ 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 /> Nome 7wner or 0r*nsael egant'e aignetwe cortiffes the following:`I certify that in tftsperformance of the work 1(w which IN-,permit is issued.l shalt not employ any person <br /> In such manner as to beromP subject to wori inadT compensatinrl laws of faftfomia <br /> Con+rector's hiring o. .r,A cortfrsrting signature certtffes *0 fonowlnp: 'I cenity that in the performance sf the work for which this permit is issued,l shall <br /> employ persons subject to workman's compermation taws of Catifornia." <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 lesy� and r ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE ��� �. _ r� - — -- --- - - <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS { _ I <br /> PRORATION J <br /> PLUS ` <br /> PENALTY /�II <br /> OTHER A I � �-k0 1 <br /> t Z <br /> S 5 u 41I _ <br /> OTHER 3 I M lis <br /> R ceived by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />