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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> e 77=7 APPLR AVON <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application <br /> its"hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) I�m-bt]5 t�1s�ZZc( Address 7-3W W1 + LL`X� <br /> c Owner I E rr"A Pia LZl] Address GIM <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No'20q-31,b LL a'. Emergency Telephone No. t <br /> Contractor Licence No. �^ b <br /> LApplicantsName (Print) �riG �Y�2��S Tci"TfLrru rcl�.z7.Q Title C�iJ4� �QG� Date��� 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 U <br /> 3. 'K PERCOLATION TEST 3 e� <br /> R.S. or R.C.E. Name Z R.S. or R.C.E. No. I ft L, <br /> Test Location Cha�1¢S t�>vc.Zut) L A_� Test Date/Time i 4�R,-7 <br /> 4. 11 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN c� <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 /> Homeowner or licensed agent's signature certifies the following!"I certify!tint!^!!;I performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman",,•vr;:e;1 afi:1:1;'ris•f Cafdc . <br /> Contractor's hiring or sub•eontracting si/naturc ce.61io. ase :,uovn:, r e perk;m..aare el the work for which this permit is issued.I shall <br /> employ persons subject to workman's compensatiun laws of Califumia." <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 ru and reg tions of,tkle San Joaquin Local Health District. n (` <br /> APPLICANT'S SIGNATURE X / ciG <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 CHEC <br /> DATE DATE REMITTED K <br /> _I T <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER tiN�P� CES <br /> OTHER <br /> Received by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN LL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />