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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGF <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 /> rBusiness Name (DBA) _ Address <br /> a Owner _ 2 1�_Ir'JET Address— 1r j ( ( ��- i(ff�11�3 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. R <br /> L Applicants Name (Print)—��P R 1 V 7`� Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. La PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) F ' 1 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. _ 1 <br /> Equipment Parking Address W <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 /> St L cation Test Date/Time <br /> 11 <br /> ( 4. KSANITATION PERMIT �i �I n s" ) /�, , C I i <br /> ob Address/Location 7 D �`-s� i� n V r /;Vn � <br /> Owner 2 V t'1 P 2 i (/E7-1- _ Address b I�ro� <br /> I9 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0 PERMANENT ❑ TEMPORARY [Er 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 O� <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. Fl. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> -Name arvrer r:r tleo r>sad ageht's sigretu.R cnrttf?oathe 4otlotntng:"!t ertlf+tFnt in the pertorneattce of the 4.mrk for which this permit is issued,l shall not et1'I ploy any perso n <br /> In such mariner r.s to be:;orae subfect t0 4vpli:InanS cosnpi laws of Ga,ifsrlu2 <br /> Contractor's hiring or auk-nnntr8c.2irg ri!iri certifies t4a following,. "I certify that in the performance a€the work for which this permit is issued.I shall <br /> employ persons suLjeztto wc,kma:t_s coimpensafioidaws 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, and r and regulation San Joaquin Local Health District. <br /> APPLICANT'S SIGNAT RE X <br /> FOR DEPARTMENT USE ONLY )Z-3 if 2. �lyll�l <br /> Fee Is Due: 11ANNUALLY [IPER UNIT 13PER SITE 11EACH ElJanuary 1 &Received By January 31 w <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION +-�0-� jUw f yt <br /> PLUSL 1 PENALvL&( °y1 �ru Gall Gut fro �t �i. o✓G✓ <br /> OTHE —.�_ �fnes :.ruGtr I�t/Y-6V� 4-Lh L t <br /> OTHER <br /> 11 led h la.ti'i-/-4�r <Z=t- t LC 1 r--[✓' Y P6(�J'a WCp_ <br /> (qui <br /> 11,r) r.4-ell(9 •,•t_ f 1 f/its,vrt rnc/t 1 r. sf� <br /> �. V<,*- Yt'h_o�tc I-+s0- hd.- 1 d Lel j {vr 1►f/u1sw. <br /> Received by Tate Receipt No. Permit No. IIssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENWRONMENTAL HEALTH PERMIT/SERVICES ( 1eVI E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA35201 <br /> 4 t v�L C11 <br />