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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION p <br /> (For Non-Transferable, Revocable, and Suspendable) SLEP..rAr_ 1 <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) I)�tt.l^87iJ ►Jfilhliit�-�21t�Gt Address IgZD �,J. I/�T•r't-f.�tft�vJC� <br /> z Owner AMC-5 T--. 5y— Address Q3'10 it .VF-L. LaDI 4 CA <br /> J Firm Partners, Addresses and Telephone Numbers t=-tNFP.1-0�[Z tfJ<-' ��i25 �• M`{72-i t-� lert- --mc- <br /> c. <br /> -lc- <br /> aBusiness Telephone No. 714 1544; Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) G+ft Title Date -7 <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. [1 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of gAemical Toilets Stored <br /> 3. 0/PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 01 Z <br /> Test Location �� Y '�L-I-Y Test Date/Time <br /> 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 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/ nceofth¢warkw �- <br /> agnot-emploKany-offs� <br /> HoneeawlnerOtlicergsdeQent'ssipnetrwerths ! <br /> in weft matmer as to become subject to wotkltm**compeasatiott laws of Cafiiorrlia i certify that in the performance of the Work for which this permit is issued.I shall <br /> CentnctWs hiring or sub-cOrupceirs Offtatme utdAOs the fellwriep. <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,4pd rules and moulatiQns o the San Joaquin Local Health District. <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 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLA TION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ✓0 p AMOUNT <br /> FEE O`.oc� ^1 / � �i�6 .7�(7�OCI <br /> 773 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER O 51'�' <br /> OTHER r <br /> Recv by Date Receipt o. Permit No. Issuance Date Mailed Delivered <br /> A PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />