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ApVllcatfo?s Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION. _ <br /> r' (For Non-Transferable, Revocable, and Suspendable) ' SEf TAGS <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Ireb made itof car o usiness in the jurisdictional area oft an oaquin Loc I Healtthh Di trict. <br /> H Business'Name (DBA) r�c awe� �. Address_ ' . me � ��,� �T - 2r_x2 <br /> z Owner Address <br /> v Firm Partners, Addresses and Telephone Numb s! <br /> CIL Business Telephone No. a� Emergency Telephone,No. .. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title `_ Date l <br /> Please check Applicable Category (1-7)and Fill in the Requlred Information. r., , •�.. <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. + F ; CAL. License Renewal No. <br /> Capacity Gat.,Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD `{ : <br /> For July 1, June 30, 19 .3 <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ - �i R.S.'or R.C.E. No. <br /> Test ocatian Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job AddreSV4.ocation ec v Ty�6 <br /> O er S Y L- �� Address �� <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑•SEEPAGE PIT ❑ PACKAGE PLANT.- <br /> PERMANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site -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 j I <br />- Plant Capacity z No. Units Served } <br /> F <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ? <br /> i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I // <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner orttcansed agent's gig nature aertlfles thefollnwing:"I cortlfy that In thO P erftrrm ince of the work for which this hermit is issued,I shall not employ any person <br /> in such manner as,a becomy,subject To r,'orkTnar♦s corrpens,tion,aw. of%alif.rr itr" <br /> Cont.-aCtor's hiring or sub-rontractie±n ^i r.. iitw; ±log•. r r;° •_ '° =,tyo performance o!the work fpr which this permit is issued,I shall <br /> onlpioy p£IsonS 51Uject i J LNQF Cin$14 it1n3'.' `'v .'ti, <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 r les and r u ions he San Joaquin Local Health District. ; <br /> APPLICANT'S SIGNATURE X <br /> 13 <br /> FOR DEPARTMENT.USE ONLY - t <br /> Fee Is Due: ❑ ANNUALLY [],PER UNIT: ❑ PER SITE ❑ EACH '❑ January 1 &Received By January 31 ❑ July 1 &'Received By July 31 <br /> k - <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> F 'y DATE DATE - ;REMITTED AMOUNT <br /> FEE CJ, - f` r i <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY' {, <br /> } <br /> OTHER <br /> . ddd . <br /> OTHER <br /> 13 <br /> Received by Date Receipt No. Permit No. Issuan a Dat ile Delivered <br /> APPLICANT—RETURN ALL COPIES TO: *LENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZELTOP IF P. .BOM 2009 STOCKTON,CA 95201 <br /> APO <br />