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Applicati, ns Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION --I �_��o(R <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> Q ENVIRONMENTAL HEALTH PERMIT <br /> / Z l LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Na (DBA ___ ' Addresg <br /> i Owner C S c"i✓J !�r_Tc� /+��l�i''Address 14 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers - - <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. / _ <br /> a Applicants Name (Print) /9w�//j �S e !J Title �//��� � � 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. K PERCOLATION TEST <br /> R.S. or R.C.E. NameO s Rls&mr R.C.E. t4o. �lo <br /> Test Location - 'n 4_ Test Date/Time <br /> 4. ❑ SANITATION PERMIT Z2�7 13 <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 /> Home owner or licensed eoil ssigwaturecmreflQest%efottowinq: tc nfty hA?intRe�Ct/otfeoncnn�?tte�le►1cf4rwbiomisill"itisissued Ishafinotemlbyanyperson <br /> in sYch manner as to W6me1,;ubi0dlo warlcrrl c:ompensattfn laws n'Cl(itpllia. <br /> Contmetnrs hi or suAtwndttr <br /> teeng signere certifies the hAtrMl� )owity ttt>li2 In"pertormance c1 the work for which this permit Is issued.I shall <br /> employ persons sub]W toworkman's compensation laws of Ca"forms <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, am rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X "`� G / - —__ _ ____ __ - <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 1 � M �AMOUNT <br /> FEE �© Ale Le pI J00 <br /> LESS . <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _yP9 _ c 15a _ <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 />