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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION �-�/ <br /> (For Non*jranslerable, Revocable, and Suspendable) W fLy�E P�0P6-4,,-t i <br /> ENVIRONMENTAL HEALTH PERMIT Z-0 — 3ySz, -D f <br /> LIQUID WASTE <br /> Application is hereby madt3 to carry on business in the juri$dictional area of the San Jo4quin Local Health District <br /> Business Name (DBA) Z�tyj'p Address 1 <br /> Owner_'e" `-y— L ,-T Addre#s 111,70-M A91Pr7r — <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No._— <br /> Contractor Licence No. <br /> Applicants Name (Print) Title!S Title rt 6F^aD -4;rDate ------ <br /> Please check Applicable Category (1-7) and Fill In The Required Inlormatlpn <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �t <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. Q 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. Na;fnp _�DN 'OezN fes/ _ R.S. or R.C.E. No. q S <br /> Test Location /Z/fbNQ� �_— Test Date/Time <br /> 4. 11 SANITATION PERMIT Z- a'1&Z-P 775'q7S <br /> Job Address/Location -- - - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT Q PACKAGE PLANT <br /> ❑ PERMANENT Q 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 I_ocation(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 wwnwariliomweidN«tt•sNonewwoorMsstifwf!pfowrtel�'1 fecrn <br /> Satin oftheworkfor which this permit isissued,Ishall not employ any p@rsun <br /> In such manner as to become su*c►to worktaan's cw4w*atlonMors of C . <br /> Con m toxo #Orkq at wlb.aoabaotlr� , ems penis" dw t 1 Nolrrfaq: '!CO01{flu/is me pw%rraAme of the work for which MIs permit is issued.I Shall <br /> maploy lwrsoas su to warkawn s cotupess tfa 18i N Cairnfs-" <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, slate laws, and ru s and regulat' of the San Joaquin Local Health District. <br /> r <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 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMO NT <br /> FEE -- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit N0 nsuance Date Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: SNV1ffO"MENTAI.NE!►LTH Pt:flM1T/&fiRVICE6 1601 E•HAZFLTON Avg..P.O.Sou Zlle9 STOCKTON,CA 95201 <br />