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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 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) Address 13L}Q(O s H'Wy q9 FiZo"1&6C <br /> a Owner S/fin) g Address <br /> I�1 i�►77^C-A GA �533� <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. ?29--@DZ'3 —S3N3 Emergency Telephone No. <br /> Contractor Licence No. G09 LIG �8'f 11 6 <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ElPUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) /r5—,98—`7/ <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 ll.\ <br /> 3. 14 PERCOLATION TEST <br /> R.S. or R.C.E. NameL-06 yt_ T AOtJ 1f*J^J R.S.or R.C.E. No. 2 <br /> Test Location 1390,1 -sottwy 99 Test Date/Time TO (36 w✓ '4 177Ti[ t�r� <br /> 4. ❑ SANITATION PERMIT �� /J y(F I ON& 3,page- Wlilrek 0-r- /0-7_—_,9 <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 �1 <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 sertifias the following:"I certify that in the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's corlpensation laws of California." <br /> Contractors faring or sub-contracting s mature certifies the fottowing: 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 lavas of California" <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 rulesandregulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X —T=e2JQ <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE t �v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 2cJ <br /> Received by 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.Box 2009 STOCKTON,CA 95201 <br />