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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) SEPTAr F <br /> 10�7S-9/_� 3 ENVIRONME QUID HETAL AL HEALTH PERMIT <br /> Application I�herebXmade to carry on business in the jurisdictional area of the San Joaquin Local Health District/ ,f <br /> UF Business Name (DBA) i/v�/ �,ev� / 7-/�� S Address 7-a /`J r-csn'��✓� <br /> Owner Z'- /'h�OF'6��7y Address <br /> 7 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ZU� ��Z —Ul3 Emergency Telephone No. <br /> Contractor Licence No. 157 Z Z Z <br /> a Applicants Name (Print) /yam' 43 / O Title TIG/�/N�G�i4.c/ Date <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) <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. 5VPERCOLATION TEST _ <br /> R.S. or R.C.E. Name LE — � fi R.S. or R.C.E. No. <br /> Test Location '�1 Test Date/Time <br /> 4. ❑ SANITATION PERMIT �H r��� 3 3 7 <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 /> Notno owner or lied aAanYs Wilirwiftre cortNtKtM foilowlrM:"1 certftfhat 1n tflL 90rfOrltWCeef ft�lork far T Aich tMs permit is Les I Sh RZ <br /> loy arty rson <br /> in such manna(as to become subject to workman's oampensat i laws Of Calfitrrnii.' �j 'J <br /> contrac�r'a or sib-eentme" rpwatuw c*rdf*s ww fiesw.era: I certify ttfst;n ft WNrrname of the work for wtNch this permit eC,I sh <br /> erio"permis adIM to workman s conipeasation laws Of Califs,nit /X <br /> I hereby certify that I have prepared this applic ion t the work will be done in accordance with San Joaquin County / <br /> ordinances, state law rules and regul io oft aquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> / <br /> FOR DEPARTMENT USE ONLY Old <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 DUE CHECKED <br /> �j AMOUNT _ <br /> FEEdji- c0 4'. VD 4• 1`Q . "l qa q •d6 - Qd+� - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M <br /> - f- <br /> La <br /> _l 1 rQ L` l u .(`I'll I� <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PE�r M17/SErNICES 1901 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON.CA 95201 <br />