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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 0 Q D La )A Q APPLICATION <br /> 1 (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 Joa uin Local Health District <br /> y Business Name (DBA) 4� VLM&',1.1 l 9` :�a1Y Address per' �"��� <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ��3 r`�� Emergency Telephone No. <br /> Contractor Licence No. /66- 8C <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites C11 <br /> Description(Make/Yr., Color) —�7 <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. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. 0 <br /> Test Location Test Date/Time <br /> 4. U?r SANITATION PERMIT <br /> Job Address/Location 3d� pooi9SS�+'� � y <br /> Owner Aoo L /4-1 d ey, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER /�/LTey lQc� <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 /> Homeownerorfieensedagent's signature cartifiesthefollowing:1certifythat intheperformance oftheworkfor whichthispermitisissued,Ishall not employ any person 111 <br /> In such manner as to become subject to workman's compensation laws of California.' Z <br /> Centractor s hiring or sub-contracting signature certifies ow following: "I certify that in the performance of the work for which this permit is issued,I shall f <br /> employ persons subject to workman's compensation laws of California." ' <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and r les and regulations of the San Joaquin Local Health District. / // �� : <br /> APPLICANT'S SIGNATURE X �L <br /> IP <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ anua &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING Ff ITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r <br /> OTHER <br /> OTHER - <br /> Received by Date Receipt No. Permit No. lsqrjance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />