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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - <br /> It (For Non-Transferable,`Revocable,"iand Suspendable) SEPTAGE <br /> 41 ENVIRONMENTAL HEALTH PERMIT <br />'r LIQUID WASTE' <br /> Application is hereby made to carryon business inthe.ju1 .risdictional.area of l.the San Joaquin.Local Health.District_ , <br /> rn Business Name (DBA) Fy p til E. /a�av 2> Y _ Address /7-1= t=. <br /> aOwner- „_�,.: :L,­ Address <br /> J Firm Partners, Addresses and Telephone Numbers Y ' r <br /> a Business.Telephone No., Emergency Telephone No. <br /> Contractor Licence No.A SAY 271. ` <br /> L Applicants Name (Print) �t-d,Y?3 ulaa� ,.._' .�. .. L <br /> Title' = Date <br /> Please 1- <br /> check Applicable Category (1-?)'and Fill in the Requiredlnformaiion x • ,,, R . <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July-1, - - June 30,=19- __ Disposal Sites - <br /> Description(Make/Yr., Color) f <br /> Serial No. 4 KCAL. License No. KCAL. 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 v <br /> iNo. of Chemical Toilets Stored j <br /> -3. ❑ PERCOLATION TEST } a <br /> R.S. or R.C.E. Blame R.S. or R.C.E. No. <br /> Test LocationT Test Date/Time <br /> 4. 0 SANITATION PERMIT { ' <br /> Job Address/Location E S �' 2Ei✓G <br /> ,Owner MY 1-n oe r—�7 06el`x� _Address <br /> k SEPTIC TANK ❑ CESSPOOL , ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLPNTw <br /> _Cq PERMANENT ❑ TEMPORARY ❑,NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction - - Disposal Site _ v <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> ti 6. 0 PACKAGE TREATMENT:PLANT_ For July 1, June 30, 19 <br /> F Operator Name - = - Where Certified <br /> ,Plant Location ` <br /> xPlant Capacity . s No. Units Served ; <br /> 7. ❑ LAUNDRY For,Julyrl;'-'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 /> Name owner or licensed agent's sigimtureceroft s*ofultowl" "t certifyttmtintheperfarnta"ceofthoworkforwhichthis,permitisissued,lshaltnotemployairyperson <br /> in Such Dunne:as to become subject toworkman's compema tori;aws of <br /> C0ltrector`s hiring or sub-contracting signature certifies the #c►kowise;,: � oetiily that jlt the Fersamiance of the work for which this permit is Issued,I shalt <br /> employ persons subject to warltman's compensation laws of California. j - r <br /> 4 1 hereby certify that l 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 5a Lin Local Health District. - <br /> APPLICANT'S SIGNATURE X <br /> F. A,. - t-. FOR DEPARTMENT USE ONLY. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER,UNIT- ❑ PER SITE ❑ EACH Z❑ January 1 &Received Jan a 31 ❑ July t &Received By July 31 , <br /> EXPLANATION <br /> PLANATION PATE DATE �E. <br /> AMOUNT DUE CHECKEDBASE BILLING REMIT <br /> C -- <br /> 1 AMOUNT <br /> - OT) <br /> FEE ' <br /> s <br /> LESS <br /> PRORATION °"• T _ t t� i r �., ,�.,. _ .. 3-�.. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -91 <br /> Received by Date t ;Receipt No. d - Permit No. Issuance ate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: t(ENVIRONMENTAL HEALTH PERMIT/SERVICES `1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> L 1 <br />