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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 is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> wne <br /> Busiss Name (DBA)�IJum dl Q Piazza Address �� �E/*W 51,4% <br /> z Owner—G ai4mik2ch Address 50moz <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. 34(06!8 Emergency Telephone No. <br /> a <br /> Contractor Licence No. //'� / <br /> L Applicants Name (Print a r tle [_/i/�[ /i Date <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. is PERCOLATION TEST A4, 15 SO &3 c rae S <br /> R.S. or R.C.E. Name 61,zo X a4ceWba R.S. or R.C.E. No. �Z S <br /> Test Location 2200 CC,?i rPnsf--cKq 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 orlicensed agent's etgnature e:eetwee em#olbwfnn;,,I certi4,that fr the performance of the work forwhich this permit is issued,Ishall not employ any person <br /> in such manner as to become subject to 1/orkrtt,^,�;s coloPensatin:l laws of Califor;:ie ' <br /> Contractor's fiirioq or subc xttraci rtl. - r ^..+w ^ettilk.* the f A5owi%-: 1 Certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compznsaion laws of California:' <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. �y <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 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE s(j <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERD, C) <br /> ived by Date Receipt 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 /> 1 — <br />