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ir� ,Appl ations71 BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r �s' APPLICATION <br /> (For Non-Transferabie, Revocable, and Suspendable) <br /> A—) ! 0 ENVIRONMENTAL HEALTH PERMIT STE'DT E <br /> L__A LIQUID WASTE <br /> Application herebX made to carryon busines in thejurisdictional area of the San Joaquin Local Health Di riot <br /> y Business N e {DBA) _ — Address _�€c,` _ _ <br /> aOwner e Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. — -� 0 o d-! �'- — Emergency Telephone No. <br /> Contractor Licence No. -3 Z Z Lequi,�Information <br /> Applicants Name (Print) `' TitleDatePlease check Applicable Category (1-7) and Fill n the <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Ju)y 1, June 30, 19 Disposal Sites - - <br /> Description (Make/Yr., Color) <br /> Serial No. _ CAL. License No. CAL. Loose P,erewal 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 -R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ "cation S(v <t � �L c <br /> Owner -" - '� Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD ;'REPAIR <br /> PIT ❑�CKAG�E PLANTr <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW L� REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19- _ _ <br /> Type Construction Disposal Site e� <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 /> "i"meownerof-Umnmrdapent•sslgnsturocerwilesthelollawin leertifythaiinthepgrformanceofttrework}rn.in such mariner as to become subiect to workman's coanpensativn ia�;s of f if �r iia <br /> Contractor'= hiring Airh this permit is issued.I sl i€no,em to a <br /> employ � � w�or9 afgnatura cer5fres the iolfori,I � t � play any person <br /> P y pErsons subfr`ct to workman's compe.isa at r*ws of fjos rre t ng' I DWI hat in the performance of the worti <br /> for whit,h this permit is issued,!shall <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, anles�la 'ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 37 ❑ July 1 &Received By July 31 <br /> BASEEXPLANATION f BILLING REMITTANCE T $ REMIT <br /> — <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> 4-S AMOUNT <br /> � — <br /> LESS -- <br /> PRORATION � — <br /> PLUS -- <br /> PENALTY V <br /> t L <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. u, p ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE. P.O.Box 2009 STOCKTON,CA 95201 <br /> { <br />