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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> a <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio <br /> ) heretby made to arty on busineAin the j risd' do al area of the S Joa in Local Health Distri - <br /> Business Name (D J A dressAve 1+ 74' .9 <br /> " <br /> i Owner Address ` <br /> J Firm Partners, Addressesan Telephone Numbers <br /> CL Q Emergency Telephone No. <br /> a Business Telephone No. <br /> -i Contractor Licence No. Z- 1 <br /> Applicants Name {Print) (9 H n.' _ Title ec Date. <br /> re <br /> ._Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l <br /> For July.1,- iz' June 30,'19 Disposal Sites rn <br /> Description(Make/Yr., C61or) <br /> Serial Nor i t CAL. License No. CAL. License Renewal No. <br /> Capacity-"•'"J '--4 �.} ' ' Gal., Weights &Measures No. [ ` <br /> Equipment Parking Address <br /> 2. ❑ PUMPFR YARD.1 I <br /> For July 1, �.Jaane30, 1.9 - <br /> No.-of Vehiclgs Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST {W' <br /> R.S.or R.C.E. Name R.S. or RlC.E. No. <br /> Test Location Test Date/Time <br /> ., <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc tion <br /> Owner �- � �-' Addfess �+ <br /> 11 SEPTIC TANK C1ESSPOOL ❑ LEACHING FIELD SFPA ,;QIT ❑ PACKAGE' LANT t <br /> 11PERMANENT ❑ TEMPORARY 11NEW REPAIR' r' ❑ OTHER, i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - Disposal Situ <br /> No. of Units Equipment'Storage/Cleaning Location(s)' i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -- - <br /> Where Certified <br /> Plant Location r. <br /> Plant Capacity No.rUnit-s,Served f' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.� � t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> lfaenaawne►grlicettrede , I L-' . �v <br /> gem'aetgnstttna►rt#fie9H+'eto!►dwF+s!q;'icertifjr•!�:•I�'fitenl�'er�rtctso'.tfsewark#prwftic_htllhspCrmitisissl�ed,lshaiinnt9A►plvyaRyFe�son'. <br /> In such mamer-as to,beCome ell 'eci to workman's rortipertsatian laws cf t;aiitarra _ r <br /> Contractor's hiring or �otareatRn9 at insturr. certifiers thet t0lowirtis: "I certify that itt the performaif"of the Work fflf WhiC ttas permit is issued,f.Sikali",` ��� <br /> employ persons subject to workman's compensation ta)erg.of California." a * <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,ang rules nd regulations of the S q "n Local Health Distric . 1 I <br /> APPLICANT'S SIGNATURE X <br /> J: <br /> FOR DEPARTMENT,USE ONLY f <br /> . i <br /> t <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January i &Received ey January 31 ❑ July 1 &Received By July 31 -N <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> _ -r, DATE - DATE REMITTED- AMOUNT <br /> FEE w t <br /> t �a <br /> LESS g tQ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER s <br /> I <br /> OTHER- <br /> ---------------- <br /> Received by Date Receipt No. Permit No. 1s once Dale Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAXELTON AVE_P.O.Box 2008 STOCKTON,CA 95201 <br /> } <br />