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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 /> U) Business me (DBA) Address <br /> a Owner Address Re, '1( '74py, limtIA1./3_ A 95385 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> o. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ,1,b61i D 15f*lArS TLSIf/a/4 dO, Title E Date -146 '8 <br /> Please check Applicable Category (1-7)and Fill in the Required Information 'moi GX "�- ss��� 1 7 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) G�1657'O�t.��F 9S3s'S <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. g PERCOLATION TEST C- <br /> R.S. or R.C.E. foie R.S. or R.C.E. No. <br /> Test Location �f Teat 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 /> Hmrne owner or licensed ogent's sign-tture cs?"wfies the following:"I rertifv th:1t;rt the performance of the work for which this permit is issued,I shall not employ any person <br /> in sJch manner as to become sub;ect to workman's cernpensation taws of Caiifnruia­ <br /> Contractor's hiring or sub-contracting signature cartifirs the following: "1 certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws 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 les and re 91, <br /> ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMEr k ONI." <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAC _J dy January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BDATJILLIiFl M TTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE OV Z Gld( � �QO c)& <br /> LESS <br /> PRORATION t <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER ! <br /> OTHER <br /> 1 Y <br /> 11a <br /> Rec�ed by Date Receipt No. Permit No. Issuance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SUVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />