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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) SEPTAIC <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 /> yBusiness Name (DBA) Addre}s <br /> z Owner 1/e P Address Z3Z¢s�4rJT4 �� c_ 54-A '7 ��e4sch <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> J Contractor Licence No. <br /> �Applicants Name (Print) C Title Date I"3�P",9O <br /> Please check Applicable Category (1-7) and Fill in the Required Information �0,`,4,Al»Oq,� le/a�/ <br /> 1. IJ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) c "�eW �70 9 �7g'�6DG <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. 95 PERCOLATION TEST / <br /> R.S. or R.C.E. Name 0 --, C , -7-;i)Sc`j Rk&mor R.C.E. No. I_5e6 ZZ <br /> Test Location !l4 7 G fZa941-1P_ Trdvl Test Date/Time PiB19N2rt/f/G✓e.�/��� 9D , �P_ad•� <br /> 4. ❑ SANITATION PERMIT r <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 CEANING, Chemicals Used/Amount/Mo. <br /> ow,eownerorlicensedagent's signature certifir,3thofollowing:"!certify th fintheperformance ofthe work for which thislpermitisissued.Ishall not employ any person <br /> in such manner as to becor^e suhject to workman's compema'.ion laws of lJ'iiforni3 in. <br /> the <br /> hiring or sub-cu:I2mcting sanaatre cart;fics -:): io!lowing: "I certify tha,ire the performance of the wodk for which this permit is issued,I shall <br /> employ persons st ;;ct to wurkmads compensaiiuu laws vi%aiifOt nla." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance ith San Joaquin County <br /> ordinances,state laws, an rules and regulations 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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -2 - <br /> %p <br /> eceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURiN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />