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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> w (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t' LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business�N,am�e (DBA) ?�'�rrG D �� �c4S�' 1 address 7i yd Ske`L�y- <br /> a Owner 1L 0 ,[1-4d14-J- <br /> C <br /> -4d L!`t" Address <br /> Firm Partners, Addresses and Telephone Numbers 1<ts:—LM d �� �;����- ����C ��� ST gyp �3KS <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> � <br /> Applicants Name (Print) �U l' n R C" 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 G <br /> 3. PERCOLATION TEST Z QR.S. or R.C.E. Name Fon 7� L J'/1/ZC/✓ R.S. or R.C.E. No. <br /> Test Location •ST _(a(-'G L• SOL• 2c� Test Date/Time <br /> 4. ❑ SANITATION PERMIT Pc7-rk,s- 4onL? Pc=oz_ L SCwoi-p- arm <br /> Job Address/Location - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT U 5 <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 /> Homeewowrw 9crasedagwrtt'a lur�eertifiasttMtoBwriug:"Iq �rintheperbratamefthtworkferwNchthispermitisissued,Ishallnotemployanyperson <br /> in such manner as tobetome$ to works #09 vompena ftn laws of Crtathatktornis." <br /> Commcior's Riring or erb-ceaftne0! sioratwc ae Uft the foaowlne: ''t oertiiy that in the performance of the work tot which this permit is issued,I shall <br /> employ persons subject to workman s compensation lam of California" <br /> I hereby certify that I have prepared hi application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es and re Wsoofhg/zSDa,,,Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X / <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S J joD. O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> Received by I 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 />