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IV <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterible,'Revocable, and Suspendable) tEPTACE <br /> ,. <br /> •- ENVIRON�A, NTI31_ HEALTH PERMIT <br /> � <br /> j LIQUID WASTE <br /> i P Appliction is hereby`made to carryon b sines in the jurisdictional area of the San Joaquin Local Health District. <br /> y Business Name (DDBA)11-- e Int AA ' -h r4(( s ati, "'"' ` Aaares5- 3 S ®"" W C L a-,-Ilr i=Mn <br /> z Owner .. e @ .. .. ti Cal l f Address 5. C-M 15 <br /> Firm Partners, Addresses a d Telephone Numbers T <br /> aBusiness Telephone No. $?- .. Z - - Emergency Telephone Na. <br /> Contractor Licence Na. <br /> Applicants Name (Print} `Title k -,.�1Sr�I Gk-i�r <br /> Please check Applicable Category (1-7) an 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) ky <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, r-.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 Location Test Date/Time <br /> 4. 9 SANITATION PERMIT,.___ <br /> Job Address/Locationz A/ <br /> Owner <br /> 1-14141,79514 'Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL �� 9LEACHING FIELD IN SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW pw REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1=June 30,.19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment—SStorage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name " Where Certified <br /> Plant Location <br /> Plant Cam cityT �. No. Units Served <br /> 7. 0 LAUNDRY For July 1, -June 30, 19)" - - - - <br /> SIZE:,, -Q,,Less Than.1,000 Sq'..Ft.;_ -.❑ More.Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner arlicensed agent's 5tgnature certifies thefoTlawi ng:"I certify th et in the perfcrmnnce of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become Subject to worklnW s compensation laws at CaEifo?o a- <br /> Contrecter's hiring or sub contracting signature certifies the follovArng: '-I certil that in the performance vi the work for which this permit is Issued.I shalt <br /> employ persons subject to workman's compensaimn laws of Cd+iforslia." R <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, and rules and regulations of the San Joaquin Local Health District. - <br /> APPLICANT'S SIGNATURE X <br /> f?IgE <br /> FOR DEPARTMENT USE.ONLY fi <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> -- _ BASES EXPLANATION DATE DATE -REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS r t <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER 1T <br /> OTHER + / <br /> yy� �S S <br /> Received 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.Boa 2009 STOCKTON,CA 95201 <br /> _ fir <br />