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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For pion;Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE M5— 9.7 7-3 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> v;Business Name (DBA) Address <br /> aOwner MARY 5An6 K1 Address Pn-Fico l 11 t• G P.L_t Fot�alA QtjZ4n <br /> J Firm Partners, Addresses and Telephone Numbers� ���� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print)WALXIIER 15- CUGZYIS Title GtylL- Et4GIWEWat Date CS-9-7 <br /> Please check Applicable Category(1-7)and Fill in the Required Information 41 g M^-MtAgW PLAZA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1-0t 1,C:AL0;Mia(a. Q52." <br /> For July 1, June 30, 19 Disposal Sites (.21n9) 3(08 - 4-159 <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 a,v,pr_ ZO <br /> Ac2t� tK�o 2 pnR�, PARc.t�. =1•o AGR>✓ <br /> 3. .� PERCOLATION TEST MSS $Z--73 PAt2+cFL la itl9 oa Ac-ME <br /> R.S. or R.C.E. Name WAk,_TV ]a R.C.E. No. tised. <br /> Test Location i 3a4R �ANAtvT 4y'nA� Test Date/Time �— l2-$"7 iI�A 4 <br /> 4. ❑ SANITATION PERMIT Ac. A�GAl.tt= NlA 952ZQ rt7vq�Z� t��l- '�L=$� f' µ0 MAKz-e (TewTftwr-) <br /> AS��vATtc�-t5 �►� $-1Z-$'1 <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 t If <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 /> G <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner or licensed agent's signature certiftesthefonowing:1certifythntintheperfonnanceoftheworkforwhichthispermitisissued,Ishallno employany ers <br /> in such manner as to become subject to workman',.compensatimf lana of f:lliion.i-Cf <br /> Contractor's hiring or sub-contracting signature. rertiiios, the tz8owing: t certify!ha'in the performance of the work for which this permit is issued.I sha '� <br /> employ persons subject to workman's compensation laws of Calilmnia." <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. <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 AMOUNT <br /> FEE U4 v V 00 <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER , <br /> OTHER <br /> eA 10 <br /> Received 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 />