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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 madejo carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) ` r Y Address <br /> a Owner AsofL- *- C�b�(��L-- Address 2-111.1 Dw � '�� �5 �� <br /> J Firm Partners. Addresses and Telephone Numbers -�t� E�- �' �y1—q5- <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> a Applicants Name (Print) C � t Title � Date Z� TUV� z- <br /> Applicants <br /> check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, — 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 /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No,�of�mical Toilets Stored <br /> Ul - <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name Vzo-P ^j R.S. or R.C.E. No. <br /> Test Location JE t-12W4V-D'56- K'9 IOS•aC-L Test Date/Time TV ge-- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Type Construction Disposal Site <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 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - - <br /> Home owner or licensed agent's si,mature oertifbea the following:"f certifvthat in the performance of the work for which this permit is issued,I shall not employ any pees^.n <br /> in such manner as to become subject to wnrkmari s ccmpensalion!aws of Cafifomia <br /> Contract(w s hiring or sub-cont.actinp signature certifies the tenowing: 'I certify that in the performance of the work for which this permit is issued.I shall <br /> employ persons subject to workman's compensation laws of Galifomia" <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, a ales d regulation a San Joaqui ocal Health District. <br /> APPLjCANT'S SIGNATURE <br /> "/2,r, �' - ,r�<: �.,•y ��^ ��J'•:�.f c / t\ �/O i, <br /> Z C % r <br /> FOR DEP fiTM 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I Ej O p <br /> FEE O <br /> LESS ^ <br /> PRORATION (/ <br /> PLUS <br /> PENALTY — <br /> OTHER <br /> OTHER <br /> ceived by ate Receipt No. /Permit No Issuance 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 />