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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) <br /> 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 /> H Business Name (DBA) Address <br /> Owner L'41111ILF- k7wbot7 Address 'i W"t L-44jt­ `P 0 CW4 O <br /> Firm Partners, Addresses and Telephone Numbers r4ML-V,04-2— y8Z6 k ` MY`mot. '1'4 8-13�{S <br /> AA Business Telephone No. Emergency Telephone No. <br /> a <br /> �Contractor Licence No. <br /> Applicants Name (Print) � -t �-�- Title �L Date G ` (� `�2 <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.t�of��1e mCall Toilets Stored <br /> 3. P YGt7COLATION TEST 1 <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location 10V8b N �9 fRe+�Tff61E 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 /> S. ❑ 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 /> Homaown mUceneedagene'ssienetur awMissthefenewirg:'1certifythat MthepsrfoTimm esfthe work for which this permit is issued.I shall not employ any person <br /> I <br /> n such manner as to become Subject to W"kmon's compensation laws of Caliki nij. <br /> Comractols hiring or wb<anvecting eipnnture t.,dfiiaa fire following, '1 cenffy that iu tha performance of the work for which this,^.crm:t is issued.I shall <br /> employ persons subject to workmans compellsallou laws of Calitomia." <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 !` d�u�les�a(/91J regulations of the a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X(�G (O`erI <br /> All P(YCSP5b't1 �z_3k+-Cr,✓ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE § REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �J AMOUNT <br /> FEE — DO Q -}�/ <br /> LESS Q <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 9Received by Date Receipt Na. Permit NO, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> alp <br />