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ApplicationswillrteProcesseawhen submittedPropertycompleted. ee sureTO sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAC` <br /> w ENVIRONMENTAL HEALTH PERMIT ®fiy <br /> LIQUID WASTE f <br /> Application is hereby made to carry on business in the jurisdic�jonal area of the San Joaquin Local Health District <br /> Business Name (DBA) LAP60 LON°F2UL'TToN AAA1.L4&F-A'FJr Address 5-75 wacow " 0 'STE 205 <br /> <Owner !JDA- LaFtJRL1I Address 10356 CaV— loop ?t ALB <br /> Firm Partners, Addresses and Telephone Numbers i(1F,11.Y•-FL.AETL lydCG Y 287h r--- AAYWVT ,- 1 S'17�a <br /> Business Telephone No. g4�" I15 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information n <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. (AJ <br /> Capacity Gal.,Weights & Measures No. 0 . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of heroical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name e- R.S. or R.C.E.No. yZ�g <br /> Test Location 3260 e'q V��SE`/ I ST1�tJ Test Date/Time <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 /> Kaasew em orllcenseeegent's signature aordlieathe fallowing:"I certify thnt in MepMnrmance of the work for which this permit is issued,I shall not employ any person <br /> in such Merrier as to become subject to workman's compersatioc lards c! <br /> Carbaelur's Nrirm or sub-contracting signature cerWi<+s the fallowing: t c^rrit•/that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workmans compensation laws of Caitfomia.' <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, andlegulra\ of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiv by Da Receipt No. Permit Na. Issuance Date Marled Delrvere0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 - <br />