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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION a <br /> (For Non-Transferable, Revocable,and Suspenoble) A i.; b+ <br /> ENVIRONMENTAL HEALTH PERMIT t�.. il'N <br /> LIQUID WASTE <br /> Application I h reby matle to car on business in the'urisdictional area of the San Joaquin Local Health District <br /> q Business Name (DBA) ��pt«?. I Ttty� AddressT.QSdkILI- �T'-tet <br /> i Owner -- ` t , <pC7 ' <br /> a Address <br /> M Firm Partners, Addresses and Telephone Numbers <br /> 'n Business Telephone No. ��-94P0:2 <br /> a Emergency Telephone No. <br /> I Contractor Licence No. <br /> e Applicants Name (Print) -� <br /> Title Date 9:EzS — ' 2 �J <br /> Please check Applicable Category (1-7)and Fill in the Required Information I <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 /> R.S. or R.C.E. Name _ _ R.S. or R.L'.E. No. <br /> Test Location Test Date/Time <br /> 4. X SANITATION PERMIT <br /> Job Address/LocationLrG,_D�I f t-.S A r • QI {�7_J � <br /> O ner F79-A&A "n I, A d-� Address Qilaogn1(39__x, J "EEL ATS 1 CAL .57 '�-J <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT C' <br /> A�PERMANENT ❑ TEMPORARY JEW -❑REPAIR ❑ OTHER C'I <br /> S. ❑ CHEMICAL TOILETS For July 1,,-June 30, 19 <br /> Type Construction Dispose)Silo Z <br /> No. of Units Equipment Storage/Cleanipg Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT .>br July 1, -June 30, 19 4 -Z <br /> Operator Name r - 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 /> Home ownerorlicenxadagenYssignature eertitiaAthelNlowirp:"I cortify that ih thepercimance of the work for which this permit is issuedj shall not employ any p- <br /> in Such manner as to become subject to wfirkman't,csmpensation laws.of Califol nia <br /> Contractor's hjring or subcontmeting signature certifies the following: "I certify that in the performance of the work for which this permit is issued.I shall <br /> employ persons subject to workrnali s compensation laws of Calitofria." <br /> I hereby certify that I have epared this application and that the work will be done in accordance with San Joaquin County <br /> t ordinances,, state laws, r s and regula ' s of the aq IH th District. <br /> APPLICANT'S SIGNATURE X.---\ R <br /> If <br /> FOR DEPARTMENT USE ONLY 4� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January/8 Received By JanuaItty 31 ❑ July 1 8 Received By July 31 <br /> a REMIT <br /> BILLING REMITTANCE S \ <br /> BASE EXPLANATION DATE DATE REMITTED L AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER V J <br /> Receivgd 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.Bo[2009 STOCKTOH,CA seen - <br /> J <br />