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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> APPLICATION i <br /> (For Non-Transferable, Reyocable,and Suspendable) SEPTAGE <br /> 41 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE- <br /> Applicatioo,s hereb made to carry business i the Jur}'�dic 'ono area of the San Joaquin Local.Healt�.pistrict <br /> L I vr1GeY L rnQl�i 01 47 47 4• E. k�r�N►wn.�'. S�[Cav <br /> rn Business Name (DBA) l <br /> aOwner .Address <br /> Firm Partners, Addresses and Te ephone Numbers T <br /> K Business Telephone No., 4 <br /> . -(-f.47,._. QLd .. Emergency Telephone No. o l <br /> Contractor Licence No. <br /> LApplicants Name(Print) L.r.. V .r Title'L Date 2�^fry <br /> Please check Applicable Category (1.-7) and Fill in the equired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19: Disposal Sites — f <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 /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 � <br /> No. of Vehicles Stored ) <br /> No. of Chemical Toilets Stored <br /> I <br /> 3. ❑ PERCOLATION TEST t <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 /J i <br /> Job Address/Locationi��f�L L'L <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT I] PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW r ❑ REPAIR OTHER j>EsTe0y -ZTQC <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site J <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' <br /> Operator Name x -.--. Where Certified" ' : y <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY ..-For July 1, -June 30, 19 +. I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f � <br /> Harm~ker orlioansedagent's eignagneQertFNestfiefetlorrirep:"I co fy that irpMe performanceof theworklIor which this penn€t is i ssued,l shalt not employ any person. <br /> in such manger as to become subject to workman's compos tipn latus of Califarmia.' <br /> Canttacmr's trirlr.V or sub-contmctir>Q Signature certifies the fotlovrlitg: ;:t CerIffy that lA the performance of the work for which this permit is issued,I shalt <br /> employ persons subod to workman's compensation lams of CallforMa." <br /> r I hereby certify that'I 'have p ared th' application a at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r s an uta ' f t S Joaquin Local Health District. { <br /> APPLICANT'S SIGNATURE X <br /> l E. <br /> F r FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July,31 <br /> BILLING REMITTANCE $ REMIT <br /> BASF EXPLANATION DATE DATE REMITTED AMOVNT DUE CHECKED <br /> AMOUNT { <br /> FEE <br /> (,J r <br /> LESS T I. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> L <br /> Received 15y I Dat# Receipt No. PerNo. - Iss once Date Mailed Delivered, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL:'HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />