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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 1=or Non-Transferable, Revocable, and Suspendabla, c•r-PTA G <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat is hereby m de to carryon bu iness Te jurisdictional area of the S?4n Joaq in Local Health District <br /> w Busines Blame (DBA) AddressLl <br /> z O, Address_ 5CL,**MC <br /> a <br /> Firm Partners, Addresses and Tele honeumbrT ers ---- <br /> Business Telephone No._ � Emergency Telephone No. <br /> Contractor Licence No. 7- <br /> Applicants <br /> Applicants Name (Print) - _- Title J�- Date L- <br /> Please check Applicable Ca egory (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..) ' t <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 Test Date/Time <br /> 4. ❑ SANITATION PERMIT G <br /> Job Addre /L <br /> at I ��. <br /> Owner � Z62/ �/l�%1��A,6.. Y1 Address-2 I go <br /> ❑ SEPTIC TANK ❑ CESSPOOL, P-tEACHING FIELD C'-SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW 13-REPAIR ❑ OTHER r- <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 Z <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall not em; �. <br /> in such manner as?o become subject to wcrkman's compens ehor:laws of califomia <br /> Contractor's hiring er sub-contracting si9na1ur4 erfifies the frAlowing: "I certify that in the performance of t1iB work for which this permit is L <br /> empioy persons subject to workman's compensa?ion!ava of California." <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, statet laws, an rules and r ula 'ons of the San Joaquin Local Health District. <br /> t : <br /> APPLICANT'S SIGNATUR&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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT, <br /> - <br /> FEE r P 5 1\ <br /> LESS <br /> PRORATION <br /> PLUS y7/ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance i7ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E,HAZELTON AVE.,P.O.Box 2009. STOCKTON.CA 95201 <br />