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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. cD <br /> APPLICATION <br /> or Non-Transferable, Revocable, and Suspend,. <br /> ENVIRONMENTAL HEALTH PERMIT 5FP�Ac' <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> 0 Business Name (DBA) IQ-itl U/Y * 6C. Address 2 s <br /> a b F Owner./�E/L O._.4ZNDC 5p� _ Address <br /> u Firm Partners, Addressesd Te ephone Numbers <br /> CL Business Telephone No. 2d �Z—/Od1 Emergency Telephone No. 42Q 7 <br /> Contractor Licence No. <br /> L Applicants Name (Print) � .-/ Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Informaiton <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. 1:1 PUMPER YARD <br /> For July 1, June 30, 19 —. �1 C�C'� 1 <br /> No. of Vehicles Stored t <br /> No. oofdf Chemical Toilets Stored <br /> 3. XPERCOLATION TEST MS # koT it 410KC441N 1 !rr7 . MAI,_ <br /> R.S.or R.C.E. Name�eyi L p. �i�yL -ce- R.S.or R.C.E. No. VY61 r <br /> Test Location _54.-4 47Ap AL-Apn& dqp Test Date/Time W144- 'YO / <br /> 4. ❑ SANITATION PERMIT 5,C)'Tiva—W /qw, IQX�Q � pvs� [&e..7E/7_ <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT I <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 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 /> ❑ DFhJrWMANINC� Chemicals Used/Amount/Mo. <br /> wnerorrcensedagent's slgnaturecertif-th'ifollowing:1C@rtiTyythat.`,13;the Work fvrwhich thla;armltisIssued 10-AP- Y <br /> in such manner as to become subject to workmen's t r,Nlpeusaitnn tabs of CaHrml; ytflV y. <br /> Contractor's hiring or sub-contracting signature c©rtlirt)r; ti�C frllowinn.' 'I Cerilfy Pat In ihu Of the work t <br /> gtsrlCi;ia+r,e OrwhiCh(i'` 9 k <br /> employ persons subject to,vurkr.;�ws c�mpe;Wa#ion laws 6t Caftfornia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County N <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 4- <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> _--- - -----Q- F -- - AMOUNT <br /> FEE1r 14 I.2_ f--C' t( <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> �r� <br />