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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,� 1 APPLICATION <br /> A. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMITS <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Address <br /> Q Owner3Tps ANCv R01H t4akJ ,/aL, Address L`' ��� I J-{ RiPO Ctc !)�=_5667 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a.Stosimess Telephone No. C409) S99 4498 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) vt['AL--�2 Cl: "t 1S Title N iL SW �Date-12-- <br /> Please <br /> ate 12--Please check Applicable Category(1-7)and Fill in the Required Information 418 MN-T-r AE-V1t`PLA-zA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) cN` '9ISZ'A-© <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. PERCOLATION TEST <br /> R sT R.C.E. Name L-( .P— U I-.a R&c-eF R.C.E. NO. <br /> Test Location 20 ne:l, -Test Date/Time(_T U-T 12- t4-`8-,R TiMPAM <br /> 4. 11 SANITATION PERMIT(SEE 0-T PLAN Ot-t *AcV-- <br /> 7140 ES l2 I5.,B V_€Ab11�5 <br /> Job Address/Location 01= �I'+�a1✓' r i:NIU C&,6 To <br /> '�� A-1C3 T1 J <br /> Owner Address M <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 /> Home owner or licensed agent's signatnrecertifigsttle fouowing:"I certify that in the performance of the work forwhich this permit is issued,t shall notemploy any person <br /> in such manner as to become subject to workman's colnpematin,n lapis of CallforrcJ" <br /> Contractor's hiring or sub-contrarting signature certifSe, the allOWing; 'I certify that in the perlormance of the work for which this permit is issued,I shall <br /> employ persons subject to wofl Md.1's Lumpensation laws of Caliton id:' <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 <br /> e�San <br /> ..•Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X h C� J4ZC <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH /El January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> lit BILLING MITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> rf AMOUNT <br /> FEE ' B�/ ♦v <br /> LESS \.._... <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Maile( vered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />