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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 jun dictional area of the n JoagL4. Local Health District <br /> w Business (dame{DBA} 4J Address; <br /> i Owner [ Address <br /> a <br /> u Firm Partners, Addresses and Telephone Nu ers <br /> a Business Telephone NojCa <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Namrin <br /> e{PtTitle DateNit <br /> ��6�--'� <br /> } <br /> Please check Applicablory(1-7)and Fill in the equired Information <br /> 1. ❑ PUMPER-VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June_3Q 19 Disposal Sites <br /> Description(Make%Yr., Color) <br /> Serial,No.- _ GAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address j <br /> 2. ❑ PUMPER YARD i <br /> I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Storedl <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST l <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Lo ation Test Date/Time,_ <br /> 4. SANITATION PERMIT !! } {�� ` <br /> Job Add ss/Location f�S2 A!, 1-4w �d t l" " I <br /> Owner _v P r-�,{'g r r— 0.-int–� � Address •© • 7�—�IL� +� <br /> ❑ SEPTIC TANK CESSPOOL ❑ LEACHING FIE LD2r,�'��EEPAGE PIT ❑ PACKAGE PLANT r� <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW 2 REPAIR ❑ OTHER V <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. �. r <br /> 11 DR CLEANING, Chemicals Used/Amount/Mo. -- <br /> Nern�ownarasUe>Ansedapent's sbreaturaeercHleiitti�!<eNvwtrl� "1ctRify thotInthepedo%mallcsoftheworkforwhichthispermitIsIssued,Ishallnotemployanyperson <br /> In such manner as to become�U:,uCt t Crkm2ri'S�arllpensatlurl laws of Cafifernie."< _ <br /> Contractor's hiring or sub-omti 'iynature cordfiu fellewinp: 't certify that in the performance of the work for which this permit is issued,i shall <br /> employ persons subject to w€31ic;na::s vu;."),.,lsdtiva law,of Cali:iurni,.: <br /> .•r 1 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, nd rules an re lations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X e <br /> Y FOR DEPARTMENT USE ONLY tr <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PEi ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DU6 CHECKED ' <br /> DATE DATE REMITTED 'mac AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER zz <br /> s <br /> Received by Date Receiii No Permit No. Ossuancla Dale Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Boli 2009. STOCKTON,CA 95201 <br />