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A plications 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 Sn Joaquin Local.Health 7 istnct <br /> rn Business ame {DBA) :t)4 %6/�(�� �6 nt S f f� x Address <br /> z Owner Ik il-�- +.�� Address r ` 9 <br /> j Firm Partners, Addresses and Telephone.Numbers <br /> 0. Business Telephone No. Emergency Telephone No. 3 <br /> Contractor Licence No. I 4 7 4 <br /> LApplicants Name (Print) 't Title _ Date 2 <br /> Please check Applicable Category (1-7)and Fill.in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) T" <br /> For July 1; ­ June 30,-19 — Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. 1 CAL. License No. CAL. License Renewal No. <br /> -Capacity Gal.,Weights & Measures No. - .l <br /> U 3 <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 r <br /> R.S. or R.C.E. Name R.S.or R.C'.E. No. I <br /> Test ocation Test Date/Time <br /> 4. SANITATION PE)F1MIT s r ; <br /> Job Add r ss/Locat'on 7 ' ' n� <br /> Oran^. +� r4 1IUV Address <br /> SEPTIC TANK` ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE LANT' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ;BJbTHER o bo—; /o1"? <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction 'Disposal SiteI <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 Sq1 Ft.,' 13 More Than 1,000 Sq. Ft. �—�✓ <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> } <br /> Home ownerorticensedg:"1rertffyylhatirttheperf9rmahCeCifhew4rt:for vahichNIS permf!fstSSGed,IsTtaitrrafemptagangpe> m1 <br /> in such manner ns to t3L'C0 s0jaC'.t8 GUIt1'pan";."Icri lags of California.' d' <br /> Contractor's ',.."nnq or sub-contracting slanavire ccrtThes tale faitowing: "1 certify that is the a,!icrnanc�of 1;e work for w;iich thus,permit is issued,I shaft <br /> employ persons subject to wcrttlnarl s c;rimpensatfon,lays of CaGiolilia." <br /> hereby certify that0haveepared thi application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state lawes re ons of the San Joaquin Local Health District. �+ <br /> I <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Pee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT _9 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1 r- a DATE DATE REMITTED AMOUNT <br /> �} <br /> FEE , V df� <br /> LESS <br /> PRORATION <br /> PLUS �f/ <br /> PENALTY <br /> OTHER <br /> E <br /> OTHER <br /> ot 13D <br /> Received by - Date I Receipt No Perrnj o. Issuance Date Mailed Delive d j <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />