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Ap Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Iror Non-Transferable,Revocable,and Suspendabl :-J SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 1 , <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District } <br /> HBusiness Name (DBA) . , #r f-1 C_ Address x `r i ,eV-Y <br /> aOwner Address 1 <br /> J Firm Partners, Addresses and Telephone Numbers 1� 1►� 1 i -iZ7� Mt'7ZT1- sT7!_I4/ g�� 'f3 <br /> aBusiness Telephone No. -_ - . .Emergency Telephone.No; . <br /> Contractor Licence No. dM <br /> L Applicants Name (Print) C.t�t17 _ ; j Title T w Date, <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 ? <br /> For July 1, - "- -June 30, 19 - Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. r CAL. License No. CAL. License Renewal No. <br /> Capacity' Gal.,Weights & Measures No. <br /> 'Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Veh' es-1 Stored <br /> No- of emical Toilets Stored <br /> 3. PERCOLATION TES j <br /> R.S. or R.C.E. Name -__ fOI�I (11N <br /> 04F— R.S. or R.C.E. No. <br /> Test Location f;klT7 Test Date/Time - y I'b4�1 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT j <br /> ❑ PERMANENT - ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1�n <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 f `a <br /> Type Construction Disposal Site r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 1:1 PAC 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. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Rome owner or licensed ' <br /> agenl'a stprlatura certlf#osiffetoi#awingr"I cert h�that in Vie perf ormanceof the work far lrrh iott t#r;s permit is issued,6;h2;1 not em p loy any person <br /> in such manner as to become sutjact to workman's cornpensaiion fav:s of Eatiirr<;,., ' <br /> Contractor fiiring �' au11 eorrt►act#n9 sigr•.alure cowfles the following;. "1 certity'ihat lit the performance Of the work for which this permit is issued,I Shall <br /> 'employ persons subject to workman s compensation laws of Caillforara." <br /> I hereby'certify that I have prepared this application and that the work will be done in accordance with,San Joaquin County <br /> w ordinances, state laws, an s a regul 'ons of a San Joaqui Local Health District. F <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - - <br /> Fee IS Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT -¢ <br /> FEE <br /> LESS i J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> APPLICANT 7 TURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br />