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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. , <br /> APPLICATION <br /> 'y (For Non-Transferable,Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in hejurisdictional area of a San oaquin Lo al Healthy istri+ct-, <br /> ,n Business Name'(DBA) D.A. ip"Src- Addressa `� <br /> I.- Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 2—' <br /> �Applicants Name (Print) Title til��A Date —S <br /> Please check Applicable Category(1-7)and Fill in the Required Information t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> - n <br /> Description(Make/Yr., Color) ~. r <br /> Serial No, CAL. License No. CAL:Liceftse Renewal No. <br /> Capacity _ Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r r r s <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored u <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SAPHTATION PERMIT <br /> Job Address/Location Z ;5- • S'rkX J fif1l <br /> OwnerA'VRaAddress fO t I 1FowiernA..), sa <br /> SEPTIC:TANK El CESSPOOL C1 LEACHING FIELD 11 SEEPAGE PIT 11 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW /REPAIR ❑ OTHER �., �, <br /> 5. ❑ CHEMICAL TOILETS--. For July}, -June 30, 19 014 <br /> Type Construction t z ._T,: Disposal Site <br /> No of.11PAUnits_ Equipment Storage/Cleaning Location(s) <br /> � <br /> 6. CKAGE TREATMENT PLANT For July 1, -.June 3,0,_19- �. <br /> Operator Name ' t Where Cdrtified <br /> Plant Location i <br /> Plant Capacity. No. Units Served <br /> 7. ❑ LAUNDRY �or'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 /> f.-omoe�vnercrucertad�:,cre'ss;gr>a::rn cerE[si�sthe:cslniri�q:"1c2;tity14',alinthe perun-inmoIti,e��arkic; ^:c;!iitisperrnii isis5u� .lshal rfoienpio ahyperse� ' <br /> in such manner a0o become subjet:t IV workman's Ccmpersati„n IS1'!S a`;"D100rnia." <br /> Contractor's hiring or sub•cefltr,eting signatur'W cartMos 1 <br /> 1 <br /> 1C' following: "ft2tify tt t n tr,$ esferalzrce el the work for which this permit is issued,I shad <br /> EIS pin y persrons subject to workmarf9 compensation laws of Calitornia." '-f <br /> hereby certify that I have prepared this application and that the work will a done in accordance with San-Joaquin County , <br /> ordinances, state laws, and r les and regulatio of the San Jo quin Lac a th trict. <br /> a <br /> • r <br /> APPLICANT'S SIGNATURE-X' <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece+ved By January 31 Q July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> O <br /> FEE 4�UO <br /> LESS. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERr, <br /> w <br /> Received by Date Receipt No. Permit No, _ IssuAince Dat Mailed- Delivered <br /> "`_� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .Box 7009 STOCKTON,CA 95201 <br />