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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 /> H Business Name (DBA) =6'�6f'IZJS YYI111--a�9M&kM 569- S. Address /ZP0 151 <br /> pY2a92vt58=�✓c�fZ� ��Z <br /> a Owner Seme Address mG-okS?'D <br /> Firm Partners, Addresses and Telephone Numbers Cl 6�:7 7— <br /> a. <br /> — <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 29 2-77-50 ' <br /> Applicants Name (Print) DAV1t] fl� �JCht sA\(oyr Title P. 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. 1K PERCOLATION TEST <br /> R.S. or R.C.E. Name AC�Aj Ih 6)N3zlr-iJ R.S. or R.C.E. No. z5M-15z <br /> Test Location /L'ortg!A! ?WC2Z4 -nA_eT'S4 Tes Date/Tim A'-9—6 t</O1�F}►v� 310c�Pm <br /> 4. 1:1 SANITATION PERMIT 6 STS �/D rA /St� <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 sgent'ssignrturs cersifies the following:"I certify that in the 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's compensate,)n taws of California.' <br /> Cowtractoi s hiring or sub-contracting signature cerSfins the following: "I certify that in tie performance o:the work for which this permit is issued,I shall <br /> employ persons subject to workman's cumpeasatiun 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, an5juleVand gulations of the a oaquin Local Hgalth District. <br /> APPLICANT'S SIGNATURE X yU.e , <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 /> BILLING REMITTANCE $ <br /> BASE PLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE Jari3lG� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �y �{ f/? <br /> OTHER l d s0 V <br /> if "CSS X90 <br /> eceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />