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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) S11 <br /> ENVIRONMENTAL HEALTH PERMITS' .+{� <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> z Owner kzrA c,-t Ap mzr Address 41 <br /> J Firm Partners, Addresses and Telephone Numbers t�Z�C ass <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. c� <br /> Applicants Name (Print) W AL-M- E. CURM5 Title G1YIL ENG Ir4=S k'_ Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information 4-Ic5 `VAA'TT-r1C-:VK PAZACom )3 —�{-1sc� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L aDl.) C-A 952 <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 /> N of Chemical Toilets Stored - <br /> 3. PERCOLATION TEST M j- <br /> t8?8P4r R.C.E. Name W8=E;Z CI-OF- IS 1t4k:t0L.R.C.E. No. �'-%-- <br /> Test Location KA_s�x5k QdAh _ Test Date/Time <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 owneror licensed agent's signature certifies thgfollowing:"I rertify that la the performance of the work for which this permit is issued,I shall not emptey any person <br /> In such manner as to become subject to wurkman's compensaticln laws ct Cali orrd <br /> Coneractoes tiring or subcontracting signature certifies the -;lowing; "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation iaws of Cdli;oraia." <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, and rules and regulations of 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ak <br /> Received by4 <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICA —RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />