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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 jurisdictionalarea of the San Joaquin Local Health District <br /> OF Business Name (DBA) Addressi Owner } Address 's=� <br /> J Firm Pprtners, Addresses and Telephone Numbers e <br /> aBusiness:Telephone No. 2-��Q'- Emergency Telephone No. 40- <br /> Contractor Licence No. a :..- <br /> i- A_ ' � ' <br /> Applicants Name {Print) Title,, <br /> -.__ 4z � Date .� <br /> Please check Applicable Category, 1-7)and Fill in the Required Information <br /> PP 9 ry( ) ., 4 _ ,,,�t �Vt.!„ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, -7 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 /> S ; <br /> 2. ❑ t:,. <br /> PUMPER YARD .:� � } <br /> For July t, June 30, 19 ` . <br /> No. of Vehicles Stored t Cr 5`k rte: <br /> No. of Chemical Toilets Stored ? U ` � • '� <br /> 3. ❑ PERCOLATION TEST } g <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 <br /> Owner Address <br /> 0SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER �I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction x Disp-Asal Site - z. C> <br /> No. of Units Equipment Storage/'Cleaning Location <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 ; ,,.• <br /> Operatoc"Name <br /> Plant Location <br /> Plant Capacity -.,­ - ; °1 •"""" . wtw t <br /> M� �• _ - No Units Served- <br /> 7. ❑ LAUNDRY For.°Ju1��iy-June 30;'1191 ^ • yE t �ir� " <br /> � s'A r <br /> SIZE: ❑ Less Than 1,000 Sqs Ft ❑ 'b�e`xhan 1,000 Sq.,Ft. <br /> ❑ 6 R CLEANING, Chem lcalstUsed/AmountfMo:" w <br /> HomeowrrerarliCeNsedagarlt'Brig+ta recertNlestheWowstIlp'l ertifythatfitheprhMaftceoftMworkfarwtttchthispermitisissued,IshAVnote ploy any pi—u; <br /> in sack manner as to become subject to workman's conpensatlan taws of California." ¢ <br /> Ct►rst�actor'a flarirtq=or-autt�corttactinti :a�natrue cpniflsa the f Hemitlnp: 1 edify Mat intfie pall Imance of the Werk for which this pdrmit is issued,I sha"i <br /> $ploy PersOns sub)W 10 w0irkmarf5 compensation laws of California." <br /> I hereby certify that I have prepared this application and that the work Will be done it) accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of a Sa Joa uin ocal Health District. <br /> APPLICANT'S SIGNATURE X 07 <br /> *� , <br /> V <br /> m FOR DEPARTMENrUSE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACh, ❑ January 1 &Received By January 31 ❑ July 1 &Red By July 31 ` <br /> -- --. .Ju.._ Received <br /> - - <br /> BILLING REMITTANCE $ <br /> BASE - EXPLANATION AMOUNT DUE CHECKED <br /> ( DATE t r DATE REMITTED AMOUNT <br /> rg FEE <br /> LESS '1 <br /> PRORATION ,. "• y. _� ' S. - I. .. <br /> PLUS <br /> PENALTY <br /> A. <br /> r. OTHER <br /> ._.OTHER.,. a .;:.. ..T, <br /> 1 1 c{ d <br /> .. Received by Date - Receipt No. Perm No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL'COPIES TO:" ENVIRONMENTAL HEALTH PERMITISERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> i # r <br />