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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> c -1 l� (For Non-Transferable,Revocable,and Suspendable) SEPT ACE <br /> "k �, ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby made to carry on business in the jurisdictional area of the S n Joaquin Local Health District <br /> a;Business Name (DBA) AIL Fuller Address 1662 Warfield <br /> z Owner A.L. Fuller Address Same <br /> a <br /> Firm Partners, Addresses and Teleph ne Numbers -� <br /> Chi858�44L51 <br /> a Business Telephone No. _ _ -.�mayy Emergency Telephone No <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <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) <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.C.E. No. <br /> Test Location Test Date/Time <br /> 4X3 SANITATION PERMIT <br /> Job Address/Location 10343 S Airport Manteca, Ca 95336 <br /> Owner George Dennis Address 10343 S Airport Manteca Ca 95336_ I <br /> U EPTIC TANK 1:1 CESSPOOL IM LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> J� PERMANENT ❑ TEMPORARY 4NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site �1 <br /> No. of Units Equipl'ilent Storage/Cleaning Location(s) 4r <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 /> Home owneror licensed agent's signature cer*W"eth4f9tilorting I t Prtfv.h ; n the performance of the work for which this permit is issued,I shat;not employ arty person <br /> in such manner as to become subject to workman +,oboe 1s + 1i 1-zi+ <br /> Contractor's hiring or sue-contract ng si stur. Lnrt° u,;,3 1 cc tify tile:in the Wforrrnce of the work for which this permit is issued,i shall <br /> employ persons subject to wotkman's compeasaaoii laws,u+ <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 reWilation f 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 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> � L <br /> LESS <br /> PRORATION <br /> ko <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -- �-���$ Z-k cL �y� tit ae a <br /> Received by a Receipt No. Permit No. issuiI22eD to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O..Box 2009 '" STOCKTON,CA 95201 <br />