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wppuwuuns mn oe rr sea nnen oUoMma. rruyeny V... , ee a to mgn r ne nppueauun. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made carryon busines in the jurisdictional area of the an Joa uin Local Health District <br /> H Business Name(DBA) .� 4- /L is semSo 9-I Address � / - ,ST�re� 93 Zo <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> Business Telephone No. 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title gn Date 10-G-B`L <br /> trsr Please check Applicable Category(1-7)-and Fill in the Requ red 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 /> r Equipment Parking Address <br /> 2. ❑ PUMPER YAfiD <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. ❑ SANITATION PERMIT <br /> Job Address/LV,Cratt n sr /YC✓TCS fOatiC BILA G�-s <br /> Owner 140E ��-a!;,e a.0'! Address�"^L <br /> r 0 SEPTIC TANK ❑ CESSPOOL E LEACHING FIELD ❑ SEEPAGE-PIT -❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 0 NEW ❑' REPAIR ❑ OTHER <br /> S. ❑ 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 /> I. Operator Name Where Certified' <br /> Plant Location <br /> 1 <br /> Plant Capacity - No. Units SCrved <br /> 7. ❑ LAUNDRY --For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowmroriicensedagent'aslpue mcordfleathefogowing"1certify that intheperformaice of dlework forw"thispermtisissued,I shallnotemploy anyperson <br /> in such manner-as to become subject to woftnan's compensationlaws of Cai;Witi,,^,- _._ _ . <br /> Contractor's hiring or sub-contracting z1fmatore certifies, the folbwin : 'I certify t <br /> h31 in the pedormarice of the work for which permit is issued.t shah <br /> employ person}.subject to workman's compensation laws of California" g <br /> I hereby certify that I have prepared this application and that the�yvor� will be done in accordance with San Joaquin County <br /> ` -ordinances, state laws, and ru and regulations of the.San J In Local Heal tract. <br /> APPLICANT'S SIGNATURE X <br /> a. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a.Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> bw BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> / ' AMOUNT <br /> FEE S d <br /> L LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /631p7 <br /> Received by - Oate Receipt No. Permit No. Is ante ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.0.4009 STOCKTON,CA 95201 <br />