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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 tAS_90_kc_^� <br /> LIQUID WASTE PAFr_SL Z—I.51 ACI D <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Address <br /> I'_ <br /> a Owner Wt4ALZ�4_-MAMNEL TIAIL..IPS, Address 2 n <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> L Applicants Name (Print) li T(Z Title r iVIL rzt4Q 00 Q Date 4 9_'y(J <br /> Please check Applicable Category (1-7)and Fill in the Required Information 4,18A I�j ��Zfl <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (oj)}/GA. 95,2AO <br /> For July 1, June 30, 19 Disposal Sites r 7b_in 1-.7., —,¢(f 9 <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 PAW-VEL* MS--9®-10 j <br /> 1 R.C.E. Name WAL'eER_ E _ 4Ll.l19tr.15 X;8:;8RR.C.E. No. <br /> Test Location tZ Le Test Date/Time MEFAiZS ANn �oht�_rEF�nt.A'IlessJ <br /> 4. ❑ SANITATION PERMIT "' QvAD rrr QF RATES aN 4-•11-90 AAA <br /> Job Address/Location CF RAY RO YvIT}I'!>-T/l'W- 141Gr yJt1Y I <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: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner ov!icerscd agent's signature e�­ "I certify thafln the performance of the work forwhich this permit is issued,I shall not employ any person <br /> In such manner as to become sub;ect t, v w::�f i'a1tl <br /> Contractor's hiring w sub-contra.tint� « `,t:owrng: 'i certify that in the performance of the work for which this permit is issued,I shall <br /> employ persona of kiiian's of <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 Lha ( //ham <br /> `7 C_) <br /> L_J,'4hesitc L <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 /> u_DDATE /� �DATTE REMITTED AMOUNT <br /> FEE �J1 T -( r—( ^(C7 0,00 -3L-7 <br /> J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> on <br /> OTH/ERRj,•(Ln� <br /> Recei by Date R t 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 />