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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION �f <br /> ' fir Non-Transferable,Revocable,and Suspendabloilli SEPTAGE I' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Distri t "'L- <br /> r Business Name (DBA) Address <br /> i Owner c N.06 a ` SS 'J N'T r='S. Address '"'$�i rry Md.3 LEY RD STDG-1G i C <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> a r LLdil t_>; S E S Title J W r•NE1Z Date <br /> Applicants Name (Print) �d <br /> `-Please check Applicable Category(1-7)and FIII in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites V 1 <br /> Description(Make/Yr.,Color) — <br /> 'xa Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights S Measures No. <br /> Equipment Parking Address - - <br /> r, 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - ------- <br /> �x 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. _— <br /> l?"k-Location Test Date/Time <br /> 4. III SANITATION PERMIT <br /> 7Address/Location `146._b4__._' S-60 T 4 AF b 4g 9 - -y1 D 5 Iiia e Y Ra <br /> Owner C .y A,; L nc SATFS Address b446 S boot-L.; RD 'ATO c-t<T b/J <br /> _ 6-SEPTIC TANK ❑ CESSPOOL Z& LEACHING FIELD 19 SEEPAGE PIT ❑ PACKAGE PLANT <br /> .PERMANENT ❑ TEMPORARY R(NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 a-CSOP� 'G�.As <br /> Type Construction Disposal Site I L Yx V h to YAUMT <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 4. <br /> Operator Name Where Certified (] <br /> Plant Location 'I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 18 (n <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ! <br /> in such annex stobcomc nYssl lroturncertifieathafollowl :"f certify that In the performance ofthe arork forwhich this permit is issu^d Isballnetern <br /> in such.manner as to become stIN,,r re wnrkman s compensation laws of Califerr.;,: <br /> ColKraes+r's hiring or, sub-cone attit;.q atananve carafias the toRowirp: 1 certify Mat in the performance of line work for whiz'employ subject to workman's compeasation laws of California" " <br /> 1 hereby certify that I have prepared this application and that the work will be done in accorq�nce wiSan Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District 11'4A `5 � <br /> laa APPLICANT'S SIGNATU X C� <br /> r FOR DEPARTMENT USE ON <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH J any 1 A Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING TTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> aa <br /> FEE <br /> LESS <br /> PRORATION \:= - <br /> \a <br /> PLUS <br /> PENALTY ^v <br /> OTHER <br /> OTHER <br /> Received by le Receipt No. Permit No. la5uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITAIERVICES tai E.HA ELTON AVE.,P.O.Box 2009 STOCKTON.CA 952011 - <br />