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Applications Will Be Processed When Submitted Properly Completed:BeSureToSignTheApplication. <br /> APPLICATION <br /> `�����v let, X ( (For Non-Transferable, Revocable, and Suspendable) SEp AGE <br /> "� ® ENVIRONMENTAL HEALTH PERMIT ti- d-z <br /> i �I ZD G-��o LIQUID WASTE <br /> jr f Applica'tiol�hereby made carry on business in the jurisdictional area of the San Joaquin He th DIS rict <br /> OFBusiness Name (DBA) bUTCR - Address— 7 f <br /> z Owner Address <br /> Firm Partners, Addresses and Tele hone Numbers <br /> CL 15_ Emergency Telephone No. <br /> m Business Telephone No. <br /> A Contractor Licence No. 1 <br /> L Applicants Name (Print) 7:s;� Title Date <br /> Please check Applicable Category.(1-7) and Fill in the Reqtwormatio, <br /> a <br /> J. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, :June 30,-19' -- Disposal Site <br /> Description(Make/Yr., Color) _ �� _ F R - M <br /> ._ �_._. CAL. License No. CAL. License Renewal No. { <br /> Serial No. <br /> Capacity` Gal., Weights &Measures No. 01 <br /> Equipment Pawing Address <br /> 2. ❑yPUMP ER YARD <br /> For Juiy.JL�t�une-3D,.19~-~ <br /> No.of Veliiclgs Stored <br /> No. of Chemical Toilets Stored <br /> 1 3. ❑ PERCOLATION TEST �. 7 ' <br /> t R.S. or R.C.E. No. t ` <br /> R.S. or R.C.E. Name I <br /> Test Location ' Test Date/Time ' <br /> 4. Jq SANITATION PERMIT <br /> Job Address/Location <br /> y Owner A�P/P.Y1 P ' Address' <br /> ❑ SEPTIC TANK~❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY ❑ NEW REPAIR t ❑ OTHERn� a -d <br /> 5. 11 CHEMICAL TOILETS"-For July 1,-June 30, 19 f il�61iZ 14Q k• F' � <br /> Type Construction_ Disposal Site <br /> � a [ <br /> No. of Units Equipment.Storage/Cleaning Location(s) <br /> { <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> - Where Certified <br /> Operator Name = <br /> Plant Location k <br /> Plant Capacity �k No. Units Served <br /> ,7. ❑ LAUNDRY Foi 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. N1f <br /> Nome owner orticensedagant's signaturecerlifies4bdfoltowing:"I certify that in the performance of thework for wbich this permit is issued,l shall not employ anyperson <br /> in such manner as to become subject to workman's t ompcns2tien laws Of California." <br /> Contractor's hiring or s,rb-contrasting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall',., <br /> employ persons subject to workman s compensatioh laws of California.'• <br /> i sir <br /> I hereby certify that 1 'have prepared this application nd the wor will be done in accordaflce with'Sa�I Joaquin-County�",?�/ <br /> ordinances, state laws;and r les and regulations o Joa in dal Health District. T <br /> r <br /> APPLICANT'S SIGNATUREX t' <br /> FOR DEPAR ENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January1 &Received By January 31 0 July 1 &Received By July 1. <br /> MIT - <br /> BASE EXPLANATION BILLING '' REMITTANCE $ AMOUNT DUE l <br /> DATE DATE REMITTED O T <br /> FEE I ~ <br /> LESS 1.. ` <br /> PRORATION <br /> PLUS <br /> PENALTY ------------ <br /> OTHER . 4- <br /> OTHER 4-OTHERAor <br /> t � <br /> Received by Date Receipt No Permit No. : issuan Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H LTON AVE.,P.O.Box 2009' STOCKTON,CA 95201 <br /> .�, .._......,..-ter.-.�... <br />