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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheAppucauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEETAGE <br /> .. - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE V <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) --*4 5; fIV Address - S Z <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Emergency Telephone No. <br /> Q. Business Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title ���� ��- — Date 7 7� <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) c <br /> Serial No. CAL. License No. s CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No: ( * go _ rs <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD + " <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored _ y <br /> No. of Chemical Toilets Stored w <br /> E 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name — • R.S.or R.C.E.No. <br /> Tes Location Test Date/Time <br /> 4. SANITATION PERMIT <br />[ Job Address/Location 15Z-4 �/l]. APA TEC A. <br /> k Owner t 4 A ddress <br /> MERMANENT <br /> EPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ TEMPORAR_Y ❑ NEW REPAIR ❑ OTHER V ` <br /> s <br />} S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> Equipment Stora e/Cleanin Location s) � <br /> No. of Units9 g Location(s) <br /> I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r r. <br /> Operator Name Where Certified -- <br /> Plant Location w . <br /> Plant Capacity No. Units Served <br /> L '7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 1 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> + ❑ DRY CLEANING,Chemicals Used/Amount/Mo. �. <br /> MctneownerorEiCensCdai7a!'�L'ori$natureCv':li=ieF'".9following 1Q,11li_yriFltlle.rerfm'n7 '.rvkiriTtyIticllthispermilisissued,i,ilall.not8in,,Acyanyperso <br /> in Sidi manner m tl bnome Jublpmt to wo It IS;an'S LO:nI?CA58tRC??I.RL"io o1 <br /> Contractor's hiring or aul�-cont=acting signaturz csrtiiies the luiiowing: 'i certify that in the perfosnlance o3 the vlark forv.'ilich this permit is issued,i shall <br /> } employ persons sutrjecL to workman's compensation lacus of California." " , <br /> I hereby certify that I hav epared this.application and that t e work will b done in accordance with San Joaquin County <br /> ordinances, state laws, d r d regulation f the San J uin Local e� DNict <br /> . <br /> APPLICANT'S SIGNATURE X <br /> s <br /> FOR DEPARTMENT USE ONLY 4 '. <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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER A~ <br /> [ r ' <br /> OTHER <br /> y 2- <br /> Received by date 3 -Receipt No. Permit No. isEruance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />