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APPLICATION <br /> )r Non-Transferable,Revocable, and Suspendai 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 /> rn Business Name (DBA) .<!'d1 ��?p�!�S 7T t�C' 5e�i42 glddress A 0 9 y z'r'- 'J <br /> Owner &tou %14e c a C_ Address 2 6--e,-7 SF S e-127- 4 y <br /> j Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> _J Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information i <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. ❑ 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/Location <br /> Owner�,Lfi/<G r !Z X Address <br /> QX 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) ,c <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 or licensed;.gent.'*signature certifies the fold-wing:"I certify�na,,In the p�rforrnance of the work for which this permit is issued.I shall not employ any person <br /> in such manner as to become Subljert to workman's egmpensatim taws of californ;a" <br /> Contractor's hip ng or sestt contracting signature cttc:ifies ;h- foilo-rig: "I Certii ;hat in the performance ut the work for which this permit is issued,(shall <br /> employ persons sJbject:,v:c.rkman'S eompersa'ion ia�s c. a±i:+r;ia." Y '�' <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 and of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE b'rG�'L®t <br /> LI — so.— Z— <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 REMITTED AMOUNT <br /> FEE 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t! <br /> OTHER <br /> OTHER <br /> Received 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 />