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,+ppIcdtons win ce Processed Wnen 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 carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> 1[ Business Name (DBA)—�GI47J 1 V7^n p.n-1 _T E gddres �-k II / so <br /> a Owner VLrirQ.,tJ 6-LtL.-w1 AN Address L'o2( A S JTTin(L <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Z� 1 !!f 6 ��S Emergency Telephone No. Zd�( Cf 4?3 <br /> Contractor Licence No. <br /> wApplicants Name (Print) Dr-aa-rJ 6.11 L_Itj r�rJ _ Title 5' 0001JEEIL_ Date —17-91 <br /> 1I`C,lease 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 q <br /> 3. QKPERCOLATION TEST <br /> R.S. or R.C.E. Name C ,i G, I LJ Vt . Air R.S. or R.C.E. No. G '.3:303_3 <br /> Test Location Test Date/Time. <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <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 /> Nomeowmerorlicensed agent'saignaturece.Hftesthe following:1 certlfryvthat In theperformance oflftswork forwhich this permit is issued,l shall notemploy aoyperson <br /> in such manner as to become subject to workman's compensation laws of Ca)ifornla., <br /> Comreetor s hiring or subcontracting signatme eerg6as the fa6owing: "I certify that in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to workman's compensation laws of California:' <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 <br /> , /�j <br /> r{y�/sand <br /> Jre ulatiioor S Of e S Joaquin Local Health District. ' <br /> AXtPPLICANT'S SIGNATURE hz4�L�Jf <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATEDATE REMITTED AMOUNT DUE CHECKED <br /> p AMOUNT <br /> FEE ! •� ,.—C, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> FlI <br /> c ived by Date Recei No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES jo 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />