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_ f <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Slgn Th Application. 1 <br /> APPLICATION i <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 /> yBusiness Name (DBA) Address <br /> a Owner Gt a AddressC�O k'2a Y_O <br /> J.Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> YLApplicants Name (Print) iG De Title Date ) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0-1A <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 R Measures No. <br /> Equipment Parking Address' -2t _,A I <br /> 2. 0,PUMPER YARD. <br /> For July 1, June 30;19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST.---' <br /> R.S. or R.C.E.Name - � i R.S. or R.C.E. No. <br /> Test Location A YTvist Date/Time q� d j <br /> CZAddress/Lociltiona <br /> SANITATION PERMIT <br /> In` RCE L• Lf I„/ j!)U 1 <br /> O mer <br /> �►+^ Address G d S <br /> SEPTIC TANK ❑ CESSPOOL LEACHI FIELD 1:1SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR i ❑ OTHER <br /> 5. 1:1CHEMICAL TOILETS For July 1,-June 30, 19 m <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 1. Where Certified <br /> Plant Location # 'r <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 /> F <br /> Homeownerunccensed "I certify OftheNorkJor-%y itllthispermitisissuel,ishallnoternployanype-50111 <br /> in such 3naener as to became subject to workman's compensation laws Of Ca tfnrrltr. ” ; I ) <br /> Conbactorit hiring or sub-contracting signature certifies the rotiawring:J-cerlily that in the performance cf`t re'work-for which this permit is issued,I shall <br /> ) <br /> employ persons subject to wo►kman's comp"sation laws of Catifornia." j <br /> I hereby certify that I have prepared this application and that the work will be.done n accordance with San Joaquin County <br /> ordinances, state law;andules a regul 'ons of the San aqui ocal Lffialfh District., <br /> V. <br /> APPLICANT'S SIGNATURE X — <br /> • - r <br /> FOR DEPARTMENT USE ONLY {) Ft <br /> Fee Is Dile: ❑.ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 3;1. ❑ Juty 1 &Received By July 31 <br /> r REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ I'- AMOUNT DUE CHECKED <br /> DAT DATE REMITTED '. AMOUNT <br /> Com, $_ <br /> FEE / 44, <br /> i <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> r <br /> OTHER F s <br /> A AZ <br /> -4 <br /> OTHER _ <br /> s3f <br /> r hl) (4- 5a <br /> Received by Date Receipt No. Permit IWO. Issuance Date Mai Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' - 1401 E.HAZELTON AYE.,P.O. ox 2009 'STOCKTON,CA 95201 <br />