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Applications Will Be Processed When Submitted Properly Completed. He Sure to bign Ine Appucauvn- <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h eby made to c rry n busi less in the funs ctional area of the San Joa ulrl Local Health Distric - <br /> %s ._Address d� 7�7 <br /> Business NameA)_ �` Q ' L <br /> i Owner ��+^� — Add ess— <br /> t �o. — -- <br /> 9 Firm Partners. Addresses and Telephone N tubers <br /> CL Business Telephone No. o Emergency Telephone No.— —— <br /> a 32 zz` Z <br /> Contractor Licence No. -- - <br /> a Applicants Name (Print) Title — Date_ 3 <br /> Please check Applicable Catego (1-7)and Fill In Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <� <br /> For July 1, June 30, 19 '-_ Disposal Sites <br /> Description(Make/Yr..Color)-- CAL. License Renewal No.—_ <br /> Serial No. — —_ CAL. License 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. <br /> tored_3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.No. <br /> R.S.or R.C.E.Name .__— - <br /> Test L tion -- ---- Test Date/Time— — — <br /> q. L SANITATION PERMIT <br /> Job Address/Location— � ) I '00 <br /> � <br /> 99�iirn . � — Address— <br /> O_,w�r _ �x� ❑ PACKAGE PLANT <br /> LK SEPTIC TANK ❑ CESSPOOL �CHING FIELD SEEPAGE PIT ❑ OTHER❑ PERMANENT ❑TEMPORARY NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1.-June 30, 19 1 <br /> Type Construction-- - Disposal Site _— —_, -� <br /> No.of Units _ — Equipment Storage/Cleaning Location(s) --- —-- Az:> <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified -- <br /> Operator Name -- --- <br /> Plant Location — <br /> Plant Capacity — — — <br /> No- Units Served -- — <br /> 7. ❑ LAUNDRY For July 1. -June 30, 19 <br /> SIZE. [3 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. — —— <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ---- <br /> Rome ownerorlioensedagent's signaturo cert—hef�ltowingr"I certify that in the orrfermarceoftttework let which thispermit isissued.Ishall not employ any persern <br /> In such manner as to be:eome Subject to workman's compeesatinn I2ivs of Caliterma <br /> Comremor's hiring or aub-contracting signature cerd ies the fotlowirro: 1 certify that in the tiertormance of the work for which iris permit is i<_sue3,I shall <br /> employ persons subject to workman's compensaron laws of Calitctnia." <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 rut and regulations f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � <br /> FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT ❑ PER SITE LlFAC—H ❑ January 1 &Hecewed By Janua•y 31 ❑ July 1 8 ReceivTdERytTtu y 31_ <br /> Fee t8 042:❑ ANNUALLY <br /> BILLING i REMITTANCE S AMOUNT DUE CHECKED <br /> BASE I EXPIIANATION DATE DATE --_ REMITTED AMOUNT <br /> FEE <br /> LESS i 1 <br /> PRORATION -- r <br /> PLUS �2 <br /> PENALTY �— -- ✓ j� <br /> OTHER <br /> OTHEH !� <br /> Received by Dave Receipt No. Perml No. Issuance ate Ma ileal delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Boz 20D9 STOCKTON,CA 95201 <br />