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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) 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) i6oelz5oN ¢4s-soC. Address 270/ 5e /4&7,,oyC�Q c-./•• /��f Sroc�cr°''/ <br /> a Owner LAS L , 901'£2 s.,sSv[. Address/kC6 AJ. .Sv,t£ A . s4e,24 •C-.#7-0 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. (70y) y72 - iO1 Emergency Telephone No. q/G G <br /> 2 —92 <br /> Contractor Licence No. <br /> L Applicants Name (Print) LarL O. �/o�r2 Som/ Title / icrG� Date Z <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 SQL <br /> 3. M PERCOLATION TEST <br /> R.S. or R.C.E. Name /VEi, R.S. or R.C.E. No. <br /> Test Location I YVl3 IV LOC u57- T40—= AP LoD/ Test Date/Time /j��.rST 4n. /19v - li lave' n <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 agent's signature certffies the foltowing:"I certlfy that inthe performanceof the work for which this permit is issued,Fshall not employ any person <br /> in such manner as to become subject to wc: mai,' es ' <br /> Contractor's hiring or sub•contractinrl sicnafrar.� r1tiowing: i certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's cc.rpc ns..:;,,a .r <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 ules and re lations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 0 D/ �i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMT DUE CHECKED <br /> DATE DATE REMITTED <br /> 1 �y o C� !�(� �• AMOUNT <br /> FEE C O�pc0G7 �^ 3�C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> g- C1a <br /> R#cer by Date 5lecaipFNe— 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 />