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rappllcauons Will Be Processed When Submitted Property 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 /> Applicatioo_4i hereby made t carry on business in the jurisdictional area of the S Joaqui Local Health District <br /> ousiness�] /I.Name (DBA -� lrLt >�: / �1-10W Address r1 4,7 <br /> a Owner /11 1 • tIL�Lr�c�' Address_ S <br /> Firm Partners.Addresses and Teleplhone Numbers <br /> CL Business Telephone No 240R� 7.Z7--�� c Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) �'/�'Lf r^� Title d Date ' �"�• <br /> Please check Applicable Category pp g ry(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 r- <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name _ R.S_or R.C.E.No. <br /> Test Location — _ Test Date/Time <br /> - 4. ANITATION PERMIT .01 <br /> Job A{dress/Location__. l O7 E. {/f�igL� R,6. , s {{k 7 FIV <br /> OwnerA �L, t lraL�` Address <br /> P,SEPTiC TANK ❑ CESSPOOL 0`tEACHING FIELD O SEEPAGE PIT ❑ PACKAGE PLANT <br /> �PE'FtMANENT ❑ TEMPORE R"Y XNEW ❑ REPAIR / C] OTHER '' _ <br /> S. ❑CHEMICAL TOILETS For July 1,-June 30, 19 ,. a <br /> ve Construction r Disposal Site `� <br /> of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name 1 Where Certified <br /> Plant Location <br /> Plant Capacity ' , -No. Units Served r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19.T__._ C <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., t❑ More.Th_an1.000 Sq. Ft. - - t ; <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. 4�} . <br /> Home owner nrticensedegent'Ssi�nnu03rp-�!f;s,^.tt.mfo!'nr���� CT!j t.;ti,^�„lt pgrtorrilaT;';,'�t7i�1C�N0rkfCrwhichthispermltIsIssued.IShzilnot empfoyany persDn <br /> m suet manner as to bocure:,ub,sc:t;eninl';a^Li4 f�'i;$ y ` <br /> Contretor's Ftir'na or r.Ilreo 72:.t re[I 9iy^^,1�YU1: CGrtifia. t oa fu:icwing: -1 certify that in L' porforin�nce of the werkfor which this;emit is issued,I shall <br /> employ persons subjec:to workman's compensal on laws of Calitorniz" <br /> L:l <br /> 1 hereby certify that I have p red this application and t t e work will be done in accordanaew.with San Joaquin County <br /> ordinances,state taws,and end re uJations of t Sa J uin Local Health District. <br /> APPLICANTS SIGNATURE _ <br /> I i <br /> FOR DEPARTMENT USE ONLY r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑.I�ITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> I <br /> REMIT <br /> BASE EXPLANATION ' BILLING REMITTANCE -vr AMOUNT DUE CHECKED <br /> _ _ � DATE DATE �REMITTED _ AMOUNT <br /> FEE .._ -- - _.. LL <br /> LESS -. w. - i -- <br /> PRORATION <br /> PLUS > + <br /> PENALTY <br /> OT+iER I - r _ <br /> tt <br /> OTHER... �J* <br /> Received by Oate Receipt No. Permit No. Issua Ma"d Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELC E.,P.O.8ax 2009 - STOCKTON,CA 95201 <br />