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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Ie"14 �z <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE ZO-'5v <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application I hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA), OttiA.Q11 �C�t!/4/ Address 87 441 f!744C L.Ih?tig � <br /> i Owner Address <br /> a <br /> u Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 5'12-Z_L-9 <br /> a Applicants Name (Print) /SO Title TPiCMNlGi IQ 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. PERCOLATION TEST <br /> R.S. or R.C.E. Name ��/iV SLG,DC��� It��V �!/)R.S. or R.C.E. No. <br /> C <br /> Test Location �i0 �AyC�CL, .os/-. �� T/�lTest 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 /> Homeowner orlicensedagentssignnurecertlNestMfollowing:"IfhATMit*performanceofthe work fillif Rfhispermitisissued.Ishaltnotemployanyperson <br /> in such manner es to became subjstt to workm�►'s cea►penRation lairs of C ornia <br /> Contractors hiring or sus-contracting sig wtuon c""'O s e,. fof %vhW "1 C91" ,that in the Performance W the ww*for wtlich this permit is issued,I shall <br /> employ persons subject to wofkmalys clampensafion laws atCaitternia.' <br /> I hereby certify that I have prepared this applic tion that work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a ules and regul do oft an J uin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 I DU O -7 -3 -TCU U�4-OZ <br /> LESS <br /> PRORATION �1 <br /> PLUS q.00 <br /> PENALTY d- <br /> OTHER <br /> OTHER <br /> Re!t7ived 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.Bot 2009 STOCKTON,CA 95201 <br />