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Y <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION 01 ? <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati n is hereby mpde to cglrry on Vsiness in th�ju isdictional area of the S n Joaquin Local Health istrict <br /> rn usiness Name (DBA) S I ri <S �' Address 4v � �e <br /> Owner R berf- 14 Mea-W Address 4 6 Read <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 943 " :20.21 Emergency Telephone No. <br /> Contractor Licence No. <br /> tf(c Applicants Name (Print) S+ iL-aTitle Agen t Date <br /> se 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 p 1 <br /> 3.-0 PERCOLATION TET /^ / l - .31 <br /> R.S. or R.C.E. Name C R.S.o R.C. o. 3SJ <br /> Test Location 9 e6 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 /> insuch iatinw astobtcdoamgeesubject <br /> trnr+ + •''' . .-• » _.+»� ^^ 'rp�liurr��cer`tqrwtl fnr,vNchthis permit isissued.Ishall notemploy any person <br /> ConneseWs hiring or sub-,contracting siQnrwre cwWies the following: I ceildy that inthe performance of the work tar which this permit is issued.I 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, an rules and regulationg of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � fs� <br /> C� \ � � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t&Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �Z <br /> !0 G root..? /- — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Lfn?_ -ate --ql 803-7 <br /> Received oy 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 />