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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION `rAW,Yip � i G i��5 <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <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 District _ <br /> Business Name (DBA) PG:/ti i%� t rr- %�-+ Address ��� t: E-t.-.moi• �'T- L_ii 1!r ��.• �c'2`'•.,/" <br /> Owner "i�`� �Y f t.t=?� Address �L }!/ <br /> j Firm Partners, Addresses and Telephone Numbers <br /> = Business Telephone No. r' ~�°�`�g Emergency Telephone No. �a✓r ►" Cs% 1 f <br /> Contractor Licence No. <br /> Applicants Name (Print) Z�r'"�� ��i- Title Date <br /> Please 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 Chemical Toilets Stored <br /> 3. 19 PEPCOLATION TEST <br /> R.S. oA6jLCDName _TE'�;.^Y i •,+.-x-11 R.S. oKg DNo. <br /> Test Location 1`74'i� Va. '%'�' E'M ;-h' , "�t'��"x� L"' Test Date/Time <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 /> Homeowner or licensed 31 ant's signature cerci"ies the". IowIrr}:"I certify that i..the performance of the work ler which this permit is issued,I shill net employ any person <br /> in such manner as to become suhsect?o wnr.:ma^'s c: ��e:r::ii.,::a�•a�;E 3aLiL�rc. <br /> Contractor's hiring or sub-corers.tir.E1 1 cerlity that in the parformarca ei the work fcr which the permit is issued,1 shall <br /> employ persons subject*,0 Work.;ar:s ca,ayl�Wai;�n;cLro Jf 1, .G..t:1" <br /> I hereby certify that I have pre ared this application and that the rk will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regulations of th n Jo a Local Health District. <br /> ICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R eived By nuary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BA E E LA T T EM TED AM NT DUE CHECKED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHE 12 <br /> 17 <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.Box 2009 STOCKTON,CA 95201 <br />