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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) c <br /> ENVIRONMENTAL HEALTH PERMIT ,/� Joh S7/-O/ <br /> LIQUID WASTE F <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) SG"APM4y f=AIZMS _ Address - _Z$a $ CiI�T��6 /�.� - 3�s/LYJAl <br /> aOwner _ Address <br /> J Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Z e,;R <br /> a Applicants Name (Print) ��NF 'Y /e '� Title Date Z-« <br /> Please check Applicable Category (1-7) and Fill 14 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Tact n to/Time <br /> 4. 1:1SANITATION PERMIT S E G01eIJt �� /IdUee�'l(Y L'd�U�T�L�f3nC� <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed agent's signature certlresthe following``Ce That t^ttte per�r!nancp,rA tReworll ter which this permit is issued,l shall not employ any person <br /> in such manner as to become subject to wo-katan corn;;z cosation larw,of Cah,'drr.r. <br /> Contractor's hiring or tub-contracting signature certifies the following: I certify that in the performance of the work for which this permit is issued.I shall <br /> employ persons subject to workman compensation laws of Calitornia." <br /> I hereby certify that I have prepared this applic io nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regulat n of Sa 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE <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 /> APPI ICANT_RETIIRN ALL COPIES TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bei 2009 STOCKTON.CA 95201 <br />