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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The A llcatio� `� "1 "1 <br /> ,e APPLICATION '. j , � � <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> $ZO7 ENVIRONMENTAL HEALTH PERMIT �� <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local HealtA'l� T ,L HEAL <br /> TH <br /> rn Business Name (DBA) Bak) �bt�h � 4ha7-Zo. Address 323 �✓. EL/VV 5 'I.���trL- <br /> aOwner \� 1�Ia,Zzo* 1 Address SO.r-%a. ` <br /> J Firm Partners, Addresses and Telephone Numbers <.aler, —B1CGLAmbae--h — SO.rnt? <br /> aBusiness Telephone No. - 3 8—�o�n I t�3 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) T� Plo 7z.- 0.-E'rlc_ S�ness/A Akle 1Z�C.1-- 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 <br /> 3. X PERCOLATION TEST <br /> R.S. or R.C.E. Name 7-e C'I('w PI O►Zz0. -*'.or R.C.E. No. 19 4 3a <br /> Test Location M�rjCeu LuiL lom kern-stroncA�a�Test Date/Time <br /> 4. 11 SANITATION PERMIT L oc1'i C N�.S ` S7—44- <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 /> ►terms ortloansedagent's signatwecerttfiesthe folitowm :�tenrtif�thatintheperf;rntanceoftheworRforwhichthispermftisissued,IshaBnotemployanyp .o�t <br /> satin h manner as to become sutyect to workman's compensation taws of Ca ifcrMa ' <br /> Contractor's Ndnql or sub-coaAseting signature certifies the following: I rert;ly"gat in theperformance of the work for which this permit is issued,I hall <br /> employ persons subject to workman's compensation laws of California" �Z ��� <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, a les and r s f 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 <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recei d by I IDaTe Receipt No. Permit No. Issuance Date Mailed Delivered <br /> LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />