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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) RdMpGGJC'*T( <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made t9 carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 4=- P/L2ZA Address CLIA 5T LD21, GA95L4� <br /> : Owner 7TE `F PJoZZA ___ Address 1 ei <br /> Firm Partners, Addresses and Telephone-Numbers <br /> Business Telephone No. Emergency Telephone No. 64- <br /> Contractor Licence No. <br /> Applicants Name (Print) _-!7E=-932,Y PIA=A Title K.• - Date 1 — 14 `4 <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. V PERCOLATION TEST <br /> R.S. orIll—C-7R)IName 7M-FZRY Fib-1ZA R.S. or .C.E No. <br /> Test Location 20,M . S'dWL, -5 1217. 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 /> Nome owner orricenssdagenYssignature certiTiesthefoltowing."Icertifythatintheperform attheworkforwhichthis permitisissued.Ishallnot employ any person <br /> in Such manner PIS!o become$uWW to workman's compensation taws of Ca ifnrnia." <br /> Contractor's hiring or sub-contracting signature certifies the following: 'I certify that in the performance of the work tar which this permit is issued I shall <br /> employ persons subject to workman's compensation laws of California." <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 San Joaquin Local Health District. w <br /> APPLICANT'S SIGNATURE X — -- - PA <br /> FOR DEPARTMENT USE ONLY SAM,Jo.A 1 <br /> Fee IS Due: ElANNUALLY [IPER UNIT ❑ PER SITE ElEACH 11January 1 &Received% Pus r U <br /> HE (N L' T'iyed By July 31 <br /> BILLING REMITTANCE $ (,f-J EMIT <br /> BASE EXPLANATION AMOUNT ET KED <br /> H/ DATE / /DATE /REMITTED NT <br /> FEE I!✓(,►cQ� �/ 1 7�� `DCj�� O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> by Date Receipt Not 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 />