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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION RoMe��G Io7Tl �0 I i�O <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to c rry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) p L�L1?./l BALH . PibZZ.,A Address 3 2'A w �LI✓I -`T L.D/n' �� 9524'D <br /> Owner `TEPMZ P—Z7_A Address W E LINA 5T L-091 f CA 95 Z4O <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. 4— <br /> Contractor Licence No. <br /> Applicants Name (Print) =Rlk PIA 7 Chil0iiTitle C__F7 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. 0 PERCOLATION TEST ll <br /> R.S. or C. Name TERRY PjLZZA R.S. o C.E No. 1 <br /> Test Location 2!001212 V• St9LVLE5 9,0 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 /> Home owner or ticansed agent's signature certifies the foflowing:"I certlfv that in the performance of the work for which this permit is issued.I shall not employ any perrcn <br /> in such manner as to become subject to workman's compensation laws of Catftrr 2. <br /> Contractor's hiring or sub-contracting signotum certifies the following: t certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to warkman's coiapeosaJon taws of California" <br /> I hereby certify that I have prep ed this application and that the work,will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru regulations of the Sa aquin ocal Health District. <br /> APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY T <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 /> o <br /> DATE <br /> / I DATEQ REMITTED AMOUNT <br /> (. <br /> FEE 7/ 1 [ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec 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 />