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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 4- NARR 1 <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAG`- <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Pz,�L�aC.I� �` P/e 2� Address'SZ 2'? W rEL141 ST. L.DDI*��,-95z4 z� <br /> a Owner TEPR_,X P/dZ�A T Address SL21 W ELIC!) cT L.64ri A Q52 4C <br /> Jif <br /> Firm Partners, Addressesd Tele hone Numbers <br /> a Business Telephone No.4L OqK06 10 Emergency Telephone No. :36q p g4! <br /> Contractor Licence No. <br /> a Applicants Name (Print) Pus-Z ZA -- Title e–_• E - Date I ` 3® " 4 i <br /> Please check Applicable Category (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) PAYMENT <br /> ENT <br /> Serial No. CAL. License No. CAL. License Renewal No – <br /> Capacity Gal.,Weights & Measures No. �(��� <br /> Equipment Parking Address FEB – 4 1a991 <br /> 2. ❑ PUMPER YARD SAN JOAQUIN COUNTY <br /> For July 1, June 30, 19 PLIBLIC HEALTH SERVICES <br /> No. of Vehicles Stored _ ENVIRi9NMENTAI MEALTk{DIVIS10t, <br /> No of Chemical Toilets Stored <br /> 3. ® PERCOLATION TEST 9l0 3 <br /> R.S. or .C.E. Name TERRY P/AZ ZA R.S. o C'F No. <br /> Test Location i'L 0 312 E I-4M Y CAa lY EV, Test Date/Time AbA <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 /> 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 l i2 d-•�A <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - -- --- <br /> Home am Pw or Iicensed opnt's signatumeerniNss the following;"I nerttfy that in tha performance of the work torwhich this permit is isstwll.I shall not employ any person <br /> in such manner as to become sub**to workman's compensation laws of Ca l!owt3.* <br /> ConlracWs hiring or sub-contracting signitum certifies the following: 'i certify that in the perlormance of the work for which this permit is issued.I shall <br /> employ persons subject to workman's compeasativa taws of Calif0lni3." <br /> I hereby certify that I have prepared Is applica d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, at 'reeguul�atio of th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ?G�G�J!/ — <br /> I <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 /> �1 <br /> DATE DATE REMITTED AMOUNT <br /> FEE L d�g.Ov �y� /-��1 l --C{ C70 <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Ref.' d 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 2009 STOCKTON,CA 95201 <br />