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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) DIUOJ P-N&IINE•�'ZtN61 Address A2,0 U9L'Vr 4ET't'j_-W&­� tAP& I 510E• E <br /> i Owner Address ('46 �A- 619-OFA24L C-T• <br /> L) Firm Partners, Addresses and Telephone Numbers I F4K)F1:WF_9_ ?'6Z6 �• KYf�t'� gT �[ILtJ, <br /> a. Business Telephone No. �ct�- (3 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) SEI 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. El PUMPER YARD � w � �Dl <br /> For July 1, June 30, 19 /J 67 <br /> No. of Vehicles Stored <br /> No.�offPhemical Toilets Stored <br /> LIQ <br /> 3. PERCOLATION TESeTr� �q <br /> R.S. or R.C.E. Name Y�t� tteztlJ2(�1J R.S. or R.C.E. No. act <br /> Test Location(rC w 121) pl-roK) e ,YA UPkY fL Tact nate/Time SC01SOuL-e- w/ 6Y9rU77?/L l/4-nJ <br /> 4. ❑ SANITA?ON PERMIT A 4A'Mrc ¢p <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 /> Nomso iwrorResnneditss mturrsosrNHsstl,sfed*vAt ,11c"tyyMdhiMeperformanoeofftworkfsrwhithffiisVOMMisissued,Ishallnotemployanyperson <br /> in such mamW as to Mom#sl bW1 to workman's compensation laws of Caflfor*a. <br /> Conumtm's bivior sub-eonvocsiap rwrbtiss ow fd ovAna: "t certify that in the pertnrmance of tns work for which this permit is issuer,I shall <br /> employ persons subject to wgrknon's4wmpedation laws of Caiifl)rnla" <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq nT <br /> ordinances, state laws, and les and regulations 4 the San Joaquin Local Health District. -r-e/ 1 tcq <br /> c <br /> APPLICANT'S SIGNATURE X <br /> T, <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receivedf bf 4 Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> J <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOOILTQN,•CA.95201 <br />