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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION �D�`,�o }y'J r <br /> (For Nan-Transferable,Revocable, and Suspendable) SEPT GE <br /> ENVIRONMENTAL HEALTH PERMIT, <br /> LIQUID WASTE <br /> r Application i, ereby madetocarry on business in the jurisdictional area of the San Joaquin Local HealP District <br /> w Business Name DBA) 7`/��I �1� _ Address <br /> z Owner -4--! --L� _ Address <br /> a —� oefa <br /> 7 Firm Partners, Addresses and Te ephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) L Title Date L 2- to ] <br /> Please check Applicable Category(1-7)and Fill the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <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 Lion It Test Date/Time —i - <br /> 4. SANITATION PERMIT � g <br /> Ja Address/L ation `� y �� i <br /> Owner O �r,, � Address r <br /> ❑ SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD C SEEPAGE PIT ❑ PACKAGt-PLANT <br /> U-PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER ' <br /> S. ❑ CHEMICAL TOILETS For July 1,=,J-une 30, 19 ' <br /> Type Construction Disposal Site <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 /> _ I f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Herne owner or licensed agent's Riynaluro certifies the Mtlowing:"l certif}yy that in the W4"ance of Me work for which this permit is issued,I shall not em ploy any person <br /> 3n such manner as to become subject to workman's cempensatiatt latvg of CaGfarltia." <br /> Contractor's hirillq or sub-contractiAq *nature Certifies 111- follow;ng: '1 certify that IR the performance of the work tot which this permit is issued,I shall <br /> Employ persanssubject to workman's compensation laws of California!, <br /> I hereby certify that I have prep ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru d re ulation of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE'X /01 <br /> FOR DEPARTMENT USE ONLY L rf <br /> 4 � <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT" <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE A L4,,S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuancorDate Mailed Delivered <br /> - APPLICANTS--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2.009 STOCKTON,CA 95201 <br /> a <br />