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Y ` ,Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> - n APPLICATION <br /> (For Non-Transferable, revocable, and 5uspendable) SEP7AGE <br /> • ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r Application:s her by. ad e to car on busine in th juri d' tion I area of the San Joaquin Loca He I h Distr"ct <br /> w Business Name (DBA) i' 1g <br /> Address Q �S�3SO <br /> rie <br /> a <br /> z Owner r Address <br /> Firm Partners, Add sses d T(klephone Numbers !_ 7 <br /> aBusiness.Telephone No. .. Emergency Telephone No. <br /> Contractor Licence No. <br /> dt Title. � ��r Date.. n <br /> Applicants Name (Print) _ h' <br /> Please check Applicable Category -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 /> t a For July 1, June 30, 19 <br /> 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 /> Y <br /> Test Location Test Date/Time <br /> t <br /> 4. (A SANITATION PERMIT J <br /> Job Address/Location <br /> Owner t 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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 4 <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 /> �fiomeownerorlicdnsn�'aysnt'ssipnatrrrecpreif;e�thafe!lnwing:"I certify th Intheperformanceofthev,or{2 urs•.hichthis permit isissued.Ishallnotemployanyperson <br /> in such manner a,to become Subjec.to riorkma�s eonlpeslsr rials farts;,f Cali! +Iia.' ' <br /> Cointrectorrs hiring or sub-contracting the toilow-g:,, ceriify;ili-vt in,zhi%performance of the work for which'this permit is issued,i shall <br /> employ persons subject to workman's compensation laws r o nia" <br /> I hereby certify that I .have prepared this plicat' nand th t th work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and.rules and re'ulatiof the S n oaq In.Local He h District. <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 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE 'i' $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION- DATE- - DATE REMITTED AMOUNT <br /> FEEi= <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> I l r <br /> OTHER � i '• <br /> OTHER <br /> issuance Date Mailed Delivered <br /> Received by Date Receipt No, Permit No. <br /> APPLICANT 'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITi$ERYlCES 1601 E.HAZELTQN AVE:,P.O.Box 2009 STOGKTON,CA 9520 <br />