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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> I%w,1For Non-Transferable, Revocable,and Suspend)<!I6) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on lwsiness in the jurisdictional area of the San Joaquin Loical Health District <br /> mBusiness Name (DBA) g[i:twtl?cit ZL F� I'�'It.�.acl, Address 1z3 �i ��CYl �cJ"t, i jy rp <br /> i Owner Ta rNe - Address t5'5w <br /> 9 Firm Partners, Addresses and Telephone Numbers '&V fG <br /> iBusiness Telephone No. �r(n g t Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) _ F" - - _ t le Te- i' Date <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 ,3 <br /> R.S. or R.C.E. Name 14-1'r r LCI�ZQ R.S. or R.C.E. No. 19 1 33 <br /> Test Location i)'. 111 v t ja ts 1$ P,.j wL Orz.le?,test Date/Time <br /> 9. ❑ SANITATION PERMIT*q051? Lbtl.c C t R15 Z4-0 ., A, '10 <br /> Job Address/Location .k .1. 'j <br /> Owner Address .. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT C <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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 /> Operator Name Where Certified <br /> Plant Location 1 <br /> Plant Capacity No. Units Served C <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/AmounVMo. <br /> Nolroownsr11r1ieenaadaaeRt's herotunearef iestMfoaowrins:"IcerlliffiyrthatMtheperformanceofthe work for which thispermitis issued,Ishall not employ any person <br /> in such mamler as to become subject to workmans compensation laws of Califiornia: <br /> Camractoh h" w aubaeMractillg signaturo certifies the toaawhig: '1 certHy that in the performance of the work for which this permit is Issued.I shall <br /> employ persons subject to workman's compensation laws otCalifo ma." <br /> I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a ived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE HECKEO <br /> DATE DATE REMITTED AMOUNT <br /> FEE § V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 3 I <br /> OTHER <br /> -W5 t��y <br /> Feceiv� Dale Receipt No, Permit No, Issuance Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.am 20011 STOCKTON,CA M201 <br />