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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION J s <br /> 4 <br /> jflth (For Non-Transferable, Revocable, and Suspendable) SFf'TF,CF <br /> ' 1� ENVIRONMENTAL HEALTH PERMIT <br /> +1 LIQUID WASTE �MS-837—u5� <br /> i Y r <br /> r Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business Name (DBA) >FbL-,OJS, . :NL. Address Yr*112-7'Z-4- STOcle-m <br /> i <br /> a Owner CDS& 91- zrS. Address PD 04), 32(n 79,9tN 144 C? 57 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 836 C24 7 7- Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) #69" GDS v Title P)QaTt M frlL 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. K PERCOLATION TEST <br /> R.S. or R.C.E. Name Rolo R.S. or R.C.E. No. 297.S�r <br /> Test Location Pig," Pmc-ez —sa4 oLA2,-j 06"07 ime <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 -�v <br /> Type Construction Disposal Site Q <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 /> Florne owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "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 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, and les and reg 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 Iss-O <br /> LESS <br /> PRORATION J V <br /> PLUS <br /> PENALTY <br /> OTHER 3 <br /> OTHER <br /> Rec ry by D e Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />