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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION /I'tmtrrweza- `3-2/01 <br /> A- $ (For Non-Transferable, Revocable,and Suspendable) SEPTAGE^ <br /> ENVIRONMENTAL HEALTH PERMIT `�� <br /> . <br /> LIQUID WASTE ,` <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Ldcai Health.District, <br /> H Business ame (DBA) Addres <br /> z Owner r Address 'v Cd <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. <br /> —,37-Z3 Emergency Telephone No. <br /> -J Contractor Licence No. <br /> L Applicants Name (Print) "V ft.0 ' Title �'� Date ' <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (lJ^\ <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 /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test ovation Test Date/Time <br /> 4. SANITATION PERMIT 11� r tl/l1 <br /> r� t <br /> Jab Address/ ovation Ce � c� <br /> OwnerAddres <br /> SEPTIC TANK CESSPOOL �EACHINGIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 1200�� X <br /> �, <br /> O,PERMANENT ❑ TEMPORARY 0,NEW ElREPAIR ❑ OTHER -6- IN <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 / v <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 /> t <br /> Home taftwirg.1 certify ttW inthe petfamance of the work forwhich this permit is isgued,I 0all not employ any person <br /> In such manner as to become subject to workman's compensation lays of Catilurttia.' <br /> Contractor's tdving or su"ontr*cOng signature ceroftes the fo"Dwir►s: "t certify1hat ire the performance of the work for which this permit is issued,1661 " <br /> employ persons subject to wai xman's compeasation 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 Counfy <br /> ordinances, state laws, and r es and regulatio of the San Joaquin Local Health District. r <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED AMOUNT <br /> FEE �v !; <br /> LESS <br /> PRORATION ryyy <br /> PLUS <br /> PENALTY SUj�I }✓ s" t O /� L J' 7 ' <br /> OTHER e) 0 V ?TSG Il kc �}1fes'1�+ 2-t, kl <br /> OTHER � 'L '1 e C 1 � <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed A d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />