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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION l <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> V� ENVIRONMENTAL HEALTH PERMIT M5- C -79ryN G LIQUID WASTE <br /> 90-Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) Address <br /> i Owner MR E"Rr�K.ERCIWN Address RIn- RnA 32?—R rfn�'hI. CA. <br /> Firm Partners, Addressesd Telep hone Number <br /> aBusiness Telephone No. �t~ 8,_c Emergency Telephone No. <br /> Contractor Licence No. __ c'Q tv 11 F;F-4- <br /> LApplicants Name (Print) trF'TI i Title CIV'tLBNGiRLM:K Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 418 "ATT14t-W PLAZA, (2cy�) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (•-O�1/ CA gr ,0 I / <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Vr.,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.�.o,(ff'Chemical Toilets Stored <br /> 3. )5l PERCOLATION TEST`}�O I t h o (Zp <br /> c 9) 41s9 <br /> R.S. or R.C.E. Name L Jbillor R.C.E.No. 11 ti>� 11;�o ' )L;3fJ <br /> Test Location E - O C �.a MAP�Test�DJate�rr.i�a PAt<c� VAI <br /> 4. ❑ SANITATION PERMIT �f{{$.r_ 05 t 5,-10'9l <br /> Job Address/Location PARC- U1M 1 2 uj{ W>iF•nl 0 <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/AmounVMO. <br /> Home ownerorlicensed agent'sdanwureceraauthe forlowi g:1 Ce"flythaf miff performanceolMeworh forwhich INS permit Is issued.lshah not employ any person <br /> in such manner as to become subjecf to workman's compensation laws of Caflfornta.' <br /> Contraetu'a Wring or subcormacfmp ivigrmture canities the faaowing: i certify that in the perferlaarlce of the work for which this permit is issued.I shall <br /> employ persons subject to workman's compensation laws at Califorriia.` <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, and rules and regulations of the SSanJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 1 (?fZA7E:J <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BAS EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEELESS <br /> �Z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />