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- APPLICATION <br /> } (For Non-Transferable,Revocable, and Suspendable) SEPTAL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f LIQUID WASTE f <br /> Application is hereby made to carry on busines in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) �LQ. �� s0 u� Address <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> o — 9�p Emergency Telephone No. <br /> i Business Telephone No. 7 <br /> Contractor Licence No. — 11 C _-/� - ,Z <br /> �Applicants Name (Print) Title J Date <br /> Please check Applicable Category(1-7)and Fill In the Required Inforfmation. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) 1 <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. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT <br /> Job Address/Location- - <br /> Owner <;gd7gm Address, <br /> ❑ SEPTIC TANK ❑ CESSPOOL ' 19 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY - 13 NEW REPAIR ❑ OTHER -� <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 r <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <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 ownerorrwensedagent'ssignaturecertAtestfiefoltow;1,fr:erti!ythilltheperformanceoftheworkforwhichthispermitisissued.fshallnot mployany person <br /> in such manner a5 li s c <br /> to become subject to workmaompanSatior,laws of C-lil"'"IL. <br /> 'I certify that in the performance of ills work for which this permit is i�sued,I shall <br /> Contractor's hiring or sub-contracting signature certifies the following: <br /> employ persons subject to workmali s compensation laws of California: <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance w, ith San Joaquin County <br /> ordinances, state laws, and rules and regulations of the an Joaquin L HealttiDistrl <br /> APPLICANT'S SIGNATURE X <br /> 10 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 8 Receiv January 31 ❑ July 1 d Rec ivdBy my 31 <br /> REMBASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION – <br /> PLUS 1yc/G G <br /> PENALTY 6 T" <br /> _OTHER <br /> OTHER <br /> (off Z Sao -8�- TON. <br /> � <br /> Received by Date Receipt No. Permit No. Issue Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 01 <br />