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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 /> Applicatio is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address e <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers .CP <br /> a. Business Telephone No. 4h_ z, Emergency Telephone No. _ Cb <br /> -Contractor Licence No. <br /> �Applicants Name (Print)—� Ct CLQa#=r'►Af2 ____. Title ;t Date .. "g3 <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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ® SANITATION PERMIT �, <br /> Job Address/Location 10833 N kbwe-k S>aereunenn <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ® SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER �^ <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 irtSlx�tt t� 33")('45 r Per Bona Cts►•-y%RCr T6 RO-STIq <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ 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 ownerorkcensedagent's signature cortifiesthe following:'9 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 wotkman's compensation laws nt California.' <br /> Contractor's hiring or sub-contracting si{1rlMurr_ certifies the follovAng: "I 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 Calim,;Iia: <br /> I hereby certify that I have prepared this applicatio�&oaq <br /> he wor will be done in accordance with San Joaquin County <br /> ordinances, state law d rule and regulations of opal 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 8,Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ��, /// AMOUNT <br /> FEE L4 9 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 13^ � � G <br /> Received by Date Receipt No. Permit No. ISsuanc Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />