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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) 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 /> y Business Name (DBA)_ I~40 yp E Address lYS~E, <br /> aOwner Address _ <br /> J Firm Partners, Addresses and <br /> /Telephone Numbers <br /> aBusiness Telephone No. f S""3 y 7�. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) &Z 0,V Z� _ Title Date /d/S'82- <br /> 1 <br /> Please cheek Applicable Category(1-7)and Fill in the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites -4) <br /> Description(Make/Yr., Color) jl <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 1 <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 ocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location Z#Ic C- 4-,ry G _ <br /> Owner Address a2/0 4AZZ-4446 PA ".b r <br /> SEPTIC TANK ❑ CESSPOOL W LEACHING FIELD XSEEPAGEPIT E] PACKAGE PLANT -7— <br /> PERMANENT ❑ TEMPORARY 0 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 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DR�I�nje�e°� I t .JJff%Aaunt/Mo_ , f ,, <br /> In such mann r s t0 `: l e subject,c�. ,...,,,. _ . .. <br /> e,.... �.mar,ceoftherfLrrk orwhichth4spermitf,issued,lshall not employanyperson <br /> Contractor's htrirl or :ub-centrac[i", :t:.:-.1 t. •, ti-_ ,;,y. ; ceri,i :;i3t;r.tha performance of zthe work for which this permit is issued,I shall <br /> employ persons subject to workman's co ilpdil5:d_,.v td 1A4o- <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 rules and regulations of the San J Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> QLAzo_OC <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 /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER14 <br /> OTHER , <br /> Received by Date Receipt No. Permit N Issfiance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />