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p Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> '3 APPLICATION 7,,3 o <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTA.G7- <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> vi Business Name (DBA) Neil- O• /a So'-/ Address&AP44 L��'� A"� 10�2'/y- S?�• <br /> i Owner �E�l- O ArdA6LSON Address <br /> Firm Partners, Addresses and Telephone Numbers fv3S• Zof- y'72-/D q/ ,t.� e Zoo- 33Y-34177- <br /> IL <br /> Business Telephone No. yr7Z /oy Emergency Telephone No. 33H�367z <br /> Contractor Licence No. <br /> �Applicants Name (Print) Nei` G Title pw,D6-ff_ 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 /> EST <br /> R.S.or R.C.E. Name /*«- ^/ R.S. or R.C.E. No. Ice <br /> Test Location 56rP" est Date/Time :ToAw• <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Nome owner orfiosnsedegent'aslanowreoerdffeathefollowing:"I cert?fvthat in!tleperformance of the work for whichthis permit isls to p ya y son <br /> in such manner as to become subject to woikman s co:rpa cation lags of Caliio::a2. c� Y <br /> ConVactor's hiring or sub-contracting signature certifies the following; �4 gcertify that in the performance of the work for which thin s f 8 <br /> employ persons suLiect to workman's compeasation laws of Caltfomia." <br /> I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, an sand regulatio of the San Joaquin Local Health strict.! <br /> APPLICANT'S SIGNATURE X <br /> F R 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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> n {{ Q —1d+ ` AMOUNT <br /> FEE e�� / l�- `1 l ' ) l Ll 10( o0 l — <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 1601 E.HAZELTON AVE.,P.O.Bos 210109 STOCKTON,CA 95201 <br />