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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> X8801 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 /> Business Name (DBA) L3aclrnhr[r./z,6 Plazm Address 323 WEZmLodi,, <br /> a Owner Glen BDA CIG — Address 32mi ltn -0a <br /> J Firm Partners, Addresses and Telephone Numbers Terj-v <br /> ome <br /> a Business Telephone No. 3bbl8 <br /> � Emergency Telephone No. <br /> Contractor Licence No. 130 <br /> � <br /> L Applicants Name (Print)G 13 <br /> /e17 0007 OT ohn V017 Rui ter, Title Cl Yll _nQr Date R$ <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 <br /> R.S. or R.C.E. Name 15 r R.S. or R.C.E. No. r'�685 <br /> Test Location Test Date/Time <br /> 4. 'S 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 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Mbwl►oMne -fte ped agent's sigmncm cert'ffn'.tM+�P "" ' • TM.^.ce of the»pork M�.a hich thfs permit is issued,l shall not employ any person <br /> in eacA ngnner as to become subject t ar'a?t:m n u <br /> Cw111s OW8 h or sub-ecntractia„ -?mm-3- <br /> V <br /> ?tnnr, . ity that ili t,c perlcr,;.,. ;,the m+ork for which this permit is issued,I shall <br /> �proy Dons subject to wurkman'sr cwtgltiIIS61uu 4"21 r.liM�.,uw. <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 /> 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 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.Boz 2009 STOCKTON,CA 95201 <br />