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AppliW4114ee Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAL <br /> NVIRONMENTAL 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 /> NBusiness Name (DBA) ) p Address <br /> a Owner /22r/-T/�Jf Address /�� ���Q�a TrGc✓C/� 95� <br /> Firm Partners, Addresses and Telephoo e Numbers <br /> a. Business Telephone Nolo bA�o��`S��17 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title 6"z E mol rl-_ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information c�JJ <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. lam" PERCOLATION TEST <br /> R.S. or R.C.E. Name -Z e�_ , R+Saw R.C.E. No. <br /> Test Location Ze `-� Test Date/Time <br /> 4. ❑ SANITATION PERMIT -.� t� IGI�Z tt-t, <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 /> Homeowner or licensed agent's s�gnatr ire certifies the fogowing:"I certify thattn the perform anre of the work for which this permit is issued,I shall not employ any person <br /> in such mariner as to become subject to workman's eompensatiolt laws Bf Cafiforttia.' <br /> Contractor's hiring or sub-contracting mature certifies the rotiowing: 1 certify that in the pertormartse of the work for which this permit is issued,I shall <br /> employ persons subject 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 accordance with San Joaquin County <br /> ordinances, state laws, an rules and regulations of the San Joaquin Loc I Health District. <br /> APPLICANT'S SIGNATURE <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ia <br /> w1 /� <br /> PRORATION <br /> PLUS / <br /> PENALTY r <br /> OTHER <br /> OTHER �G <br /> Received 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 />