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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> s APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> f�8i3ENVIRONMENTAL 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 /> Address W. G-1 m S L C <br /> rn Business Name (DBA) pknt.;mbe�'h � piaZZ�3 rTi•Z'f '�T—n---I2 Cnom— <br /> a Ownerfen 1ynLii,mbeicil Address, Sauna <br /> J Firm Partners, Addresses and Telephone Numbers Mr y' P OzzAme- <br /> aBusiness Telephone No. , G$GGi6 Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) " ^ Title C • , Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information Agent <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. Namef-,_ urn bach R.S. or R.C.E. No. 12686 <br /> Test Location 5 Ak jc �'rL waSt q1 L3% .j�(f(�tl�2Cl12bllL Test D e/Time <br /> 4..41f-SANITATION PERMI <br /> Job Addre s/Locationto 1144 <br /> Owner Address <br /> 1:1SEPTIC TANK CESSPOOL ❑ LEACHING FIELD 13SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER A41 6- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 !0 v,Qp <br /> Type Construction Disposal Site C GE <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 PpR 2 <br /> Operator Name Where Certified <br /> Plant Location ---t1f,FNSP'�"„t <br /> Plant Capacity No. Units ServedyNy--- Riv�rjlSERV <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 /> u.�.et«ar.e.�.0 pI__,,dw1*ftvAes:"t thatiatG 06ftr>'aanaaoftheworlt . VAIChtNspermit iSissued,Ishall not err.ployany person <br /> in such mznatr as is hecane Sul to min►S cetnpematlon laws of capllomia <br /> e,;,,,, or sub, � c,ftitss q,e .,,nowinQ t C41tifr igftt in the perlprmanCe of the work for which this permit is issued,I shalt <br /> Contractor•& , <br /> evoy persons subject to workmaBs cultooneation taws of Callitornid." <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 /> t o. <br /> APPLICANT'S SIGNATURE X t CIV <br /> C, <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 /> Q�1 yA <br /> LESS <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 />