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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 ,A / a�j,Z y�z -OZ <br /> LIQUID WASTE ✓d <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) 4 C e �GL(��� AddressoZ�ZS— /1�YiE'TG � S/ <br /> a Owner —IPMITS kp 4111 yC'- S i?—' Address c: 1-1A QD1,is,­ <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �� <br /> a Applicants Name (Print) 1 Itle —F(Y C L Date S — /0- <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 r(� <br /> 3. ERCN TEST, CSN fit_1 <br /> R. �®r .C.E.. Name Name �/n� ��NL R.S. or R.C.E. No. <br /> Test Location LF TYZ-—g ,� 1 ffkt/ Test Date/Time d �/T A <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address r <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 /> Home owner orfieeneed ago nVa signature eertwess the foI%v*r,9:'9 cerlifil that in the performance of the work forwhtch this permit is issued,l shall not employ any person <br /> in such manner as to beeomr,subject to werkmans compensation lavis of cawornia <br /> Contractor's hiring or sub-contracting tignotere cartiFiax the :aiiowing; 1 caridy wLi in the perto:manee of the work for which this permit is issued,i shall <br /> employ persons subject to workriac a comµellsatio:1 lawn of call? -oi:.' <br /> I hereby certify that I have prepared thi .ap c do and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and r u tw San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE (� REMITTE✓DY n AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t`�,`\/(� 5 - to-Q( <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />