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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) SEPTAG17 <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) Address 1 <br /> a Owner����lPr��j,��G/v Address 2a � 4�lG <br /> Firm Partners, Addresses and Telephone Numbers 4S g �/ <br /> a. Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. / <br /> LApplicants Name (Print) 2�tr!/1•/n C • TBS l/1 Title C"y'd Date-ZL—12C /�94 <br /> Please check Applicable Category (1-7) and Fill in the Required Information J 27- Go ot w. <br /> 1. E] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) S f�A ��A-i�'o <br /> izes) a -�ca <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. P PERCOLATION TESTS— I <br /> RSI'R.C.E. Name DSC far R.C.E. No. l S< b <br /> Test Location mss ' Test Date/Time Qe �,� <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 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed agent's signature ee•titica thA feltn,••ing:'9 rer*t`Y thr*'-'he F--r!armancc rf the 1••erk for which this permit is issued,(shall not employ any person <br /> in such manner as to become subject la vioWnali-�compensation la•,•:` r I Ca do ... <br /> Contractor's hien$ or sub-contracting sic.natu►o certifr:!s v :rticwNr;: t certify 111c:in 11710 performance C.Me work for which this permit Is issued,l shall <br /> employ persons Subject to workman's wmpensatioa taws 101 Cal;iomia." <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 Local Health District. <br /> APPLICANT'S SIGNATURE X �4' <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 EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /� /� '1 p AMOUNT <br /> FEE so .--a �O�O—1 & it <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2 > <br /> Receiv 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.Boz 2009 STOCKTON,CA 95201 <br />