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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 00:3-.C40-03, <br /> Business Name (DBA) WIL.KERSr7pi ;Zt^NS:t4 Address <br /> z Owner C AkL. WILbc1z-RMC-*.1 Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) WAL-i1CP-- 1=- C-u2n-lir, Title CIVIL. EN-r- !N r-1- Date li" Z� - <br /> Please check Applicable Category (1-7) and Fill in the Required Information A-IA 1:''tA'nJAtW yr-Lil-ZA r'lmm <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) LoDlI CA. 9544th 04c, `'IC <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 I JV <br /> 3. a PERCOLATION TEST � <br /> Mg:::bt R.C.E. Name VILA" -MR Ci %IZI-IS XS;zar R.C.E. No. <br /> Test Location Test D to/Ti e <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> 1:1SEPTIC TANK E] CESSPOOL ❑ LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER '9 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 T'M <br /> Type Construction Disposal Site �/,( f <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 licensed agent's signature certifiesthefollowing:"I certify I!1^tin the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's compensation laws of Cafifol0iA ' <br /> Contractor's hiring or sub-contracting signature certifies the following: i certify that in the performance of the work for 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 regulatio s 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �y O <br /> FEE <br /> LESS �7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 />