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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) SE.'] <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ApplicatQion is hereby made to carryon business in the jurisdictional area of the San Joaquin Local He--:::;+_ <br /> althh District <br /> � �i <br /> m <br /> Business�{Name (DBA) WQLIRL{lp� Pl10Zza Address-3-� W �Gm -7�1•0171 <br /> Q Owner {¢rry p1C3ZZQ, Address.��t>�n., Q., <br /> Firm Partners,A redd sses and Telephone Numbers ,[)Ql�,�um c1 1 mo_ <br /> Business Telephone No. �bs 61bI S Emergency Telephone No. <br /> 11 Contractor Licence No. <br /> L Applicants Name (Print) Title R 9C•EE9 Date10/ <br /> Please cheek Applicable Category (1-7)and Al In the Require 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.Jo Chemical Toilets Stored <br /> 3. IN PERCOLATION TEST <br /> R.S. or R.C.E. NaameR.S. or R.C.E. No. <br /> Test Location l6cr d, 9 E. « TTest Date/Time <br /> 4. ❑ SANITATION AERMITJ00* g .j7 AC,4rnf1, &, K-54 CIO--Lk <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT t- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -� <br /> Type Construction Disposal Site 'l l <br /> No. of Units Equipment Storage/Cleaning Location(s) (� <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 -i <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 /> ❑ f�CLEANING, Chemicals Used/Amount/Mo. <br /> °w"°'°race"a•dsa•^a••+fml.tureaattme•ih.MRowutg:'1 certify that in the performancent tbework forwhich this pennif is issued,[shall not employ any person <br /> in such manner as to become subject to workman's compensation 13w8 of fahforri;. <br /> a •oto:a h[dnq W sub-coniract ng 09rratme cerUfieV the following: I certify Phar in the performance of the work for which this pe,mtt is issued.I shall <br /> p V persons suNrXI to workman's compensation laws of California' <br /> I hereby certify that I have prepared this application and that the work will be done in accordancewith Joaquin Co <br /> ordinances, state laws, rules and regulations of the San Joaquin Local Health District. <br /> ZAAC <br /> APPLICANT'S SIGNATURE X A174- IT, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Duet❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 S 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 /> C:JILf�� <br /> Rece(re0 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.Box 200 STOCKTON,CA 96201 <br />