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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 /> v;Business Name (DBA) Z/ZNOL–Q tn6.PPA!F . y�- ZI U t7t_JQk ..ss V*.-,JT0 <br /> a Owner Address 16� ;tol Sa , rrl02 177 P-0 C4 <br /> C4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 2'5X?­9Y&'—13yS Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) D 01 itle 61904V61S-7 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. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ,Z PERCOLATION TEST <br /> R.S. or R.C.E. Name ZO" T, 1` 6e'/V R.S.or R.C.E. No. 29 Z�s <br /> Test Location Uc- r mu /N Test atq/Ti9e P /MZ <br /> 4. ❑ SANITATION-PERMttT �/� �t�// 7 1✓ �//L'�,�jr <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 /> Home owner or licensed me nt'ssubject <br /> sitter:+rn certtF4�+!,g}nL�ow.Tn9 "I certffvffhaf in theperformartce of the work for whichthis permit is issued,I shall not employ any person <br /> in such manner as to become subject to wog srlana compen�ativn dews of California: <br /> Contractor's hiri+lp or sub-contracYsnt1 sltnatx,rr Darla ns ttee foilu,ri„g:. 'I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to worhlnan s compensaticc,taws of Calitofnia.! <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 regulati of the San 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE t� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLIC T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />