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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 /> 7" 4 ' ENVIRONMENTAL HEALTH PERMIT <br /> �A-'/�_ LIQUID WASTE <br /> / Application hereby made to carry, Qn bus ess in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Ift �4 L I (t'�Z�.• Address j Z 3 yJ L N\ L C1 i <br /> a Owner _T. P 114 Z—2 A Address 1� <br /> L3 Firm Partners, Addresses and Tel hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) I I Title C Date c9 7 <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. 0 PERCOLATION TEST <br /> 446w FR.C.E. Name -r-. .f3:Sww R.C.E. No. <br /> Test <br /> A- <br /> Test Location e u ,J Test Date/Tim <br /> ,� y r <br /> 4s IT n <br /> Job Adds/Location V V 5; c4 k 7 r r� ~ yL iti C S) <br /> rgs <br /> Owner uHry .S e.";% e- 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 iL <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. / t <br /> A�� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homaownerwticsnsedapsnt'saigeet�uretieethsloftowing:"Itertifyfh?l+nthC^" `<'r: ^'�n,rftt;^ nr:t�-•rhic> ?h permitisi lnotemployanyper <br /> in such manner as to home subject to workftn's compensation laws of Calitonii.. <br /> Contractor's hiring or sub-eamactna two certifies Me !onowinfy: 1 certify ito.is ;he performanc.�,i.0 or whicob this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of Calitoraia." <br /> I hereby certify that I have prepared thi5,application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules andXegulations of the Sao Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> OTHER C <br /> R ived by ate 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 />