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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 0fv',�, APPLICATION <br /> � �{ QQc� <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE MS <br /> / ENVIRONMENTAL HEALTH PERMIT <br /> 01 LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> vF Business Name (DBA) Address <br /> i Owner WiWf-jIofv BAKE F, Address jss;o - R' \< Y PSL_-VD TRP\C.Y CA9537L <br /> a <br /> u Firm Partners, Addresses and Telephone Numbers <br /> E tklghmss,Telephone No. 2-02/t� S3,5— Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print) 'WAI �� C CQ1'RTI'S TitlleG(VIL SVA CmI1A .EP, Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 418 M ATfKBW IP LA-Z^ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Uzirst,cA• 9152-A-0 <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. A PERCOLATION TEST <br /> R.C.E. Name 'l�A,L'Z t;= � - C.t 'I PANW R.C.E.No. 11584- <br /> Test Location MAG Test Date/Time L-Mb"AT1YE) 'TLPES <br /> ON S <br /> A6�H('� R =ctiVU-5( AMA k<t>jTRAC4 ''1t�lED <br /> J (-SEE 12-14--8 h�ilvCa-S <br /> ❑ SANITATION PERMITP1—� 'N AgC K.¢�SF1��T <br /> Job Address/Location ON ILL Cf1Lt. -C'O -,5S'T SPfGIRiG bAZ�.) <br /> Owner Address A1�lD <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 agent's signature cortifies the following:"I certify that In the performance of the work for*hich this permit is issued,i shall not employ any person <br /> in such mannef as to become subject is wor"knian's compensation la+us cf.^,a ifufaia <br /> Contractor's hiring or sub-contracting •: !oj-v cortifit tr the i0;;owing: "I Certity that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's comp—_—,i eras of <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 rules and regulations of the San Joaquin Local Health District. <br /> 1,2 <br /> APPLICANT'S SIGNATURE X <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 CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> ` <br /> FEE - �v + S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> tv <br /> OTHER <br /> ReceivedY 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 />