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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4t: 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 /> cn Business Name (DBA) Bambrici24 Pict 7 Address 323 WEIM f L d4 C a <br /> a Owner Glen B.r;uwhacb Address_ �� " P_ 7 1.e)cl i <br /> J Firm Partners, Addresses and Telephone Numbers 7–act—ie de-1770 same <br /> a. Business Telephone No. 36L3 6A IS Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print)?e r John 17 RClltlP.n Title Midi EaQJ Date 3 <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. A PERCOLATION TEST MIS 88* <br /> R.S. or R.C.E. Name On R.S. or R.C.E. No. -Aft ®?6E'5 <br /> Test Location O t Date/Time <br /> 4. - SANITATION PERMIT <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 ptl/ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. fy� <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> komeOwNwor0censedagent's GlWwture Dertlifiesithe folilowine-"I ceMty that to t1w Worma"alikework for whickthis pwmit is issued,I shall not employ arty person <br /> iR such InatKler as to become subject to workman's compensation laws of Cafiiornia ' <br /> Contractors hidrsq or sub-contracting signature certifies the following: 1 certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of California <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sarl n t y <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> V;L�,; <br /> lJ <br /> FOR DEPARTMENT USE ONLY SM���C�S <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31�` eceived By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec ' d by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />