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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 1 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name _ey�� Address�2¢ �Q.ErcJO n�✓ j-r��.,k z, Cff <br /> z Owner t mM&Lad e2uar_,ey Address 24,j0A--# 222R12c%1 :143�_ <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) --,ohr+ r</? Lon. s Title C,V" �� -- Date za" yU <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. ❑ PERCOLATION TEST <br /> ,446. or R.C.E. Name �'ZJAr. M Loaeu .@--& or R.C.E. No. /6 767 <br /> Test Location 7 7-1,9/ r I1��t lc cZ cmc/ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <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 /> Homeowner or licensed agent's signature cortifies the followirri:"!c�r!ify!h�!in the performance of the work for which this permit is issued.I shall not employ any pert <br /> in such manner as to become subject to wurh:nan' cm:puaaticr.IaWt.,:!j'.:1 >nda.' <br /> Contractor's hiring or sub-conn:cling ;-;.:.rc rr. ::�r i;i: t:, lice:n;: "I ccrlify that in th;r porlormarL0 of the work for which this permit is issued,I shall <br /> employ parsons subject to vdorlanan's ilia.' <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, an rules and regulations 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 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dae Receipt No. Permit No. Issuance Date Mailed Delivered <br />