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" Applications Will Be Processed When Submitted Properly Complete a ure <br />- _ y y APPLICATION <br /> i (For Non-Transferable,Revocable, and Suspendable)y $EP7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �LIQUID�WASTE • <br /> lication s , r e to car bu the_,risdictionai area of the Sad aquin c Ith Di r'ct <br /> w APp ` ddres ` _ <br /> y Business iV (DBA Ad' ss <br /> _ <br /> :. 10.. <br /> i Owner _ <br /> _ Firm Partners,Adtlres�es and T lac N me r <br /> .Emy Teiephone.,N <br /> aBusiness Telephone No. / (V7IVY <br /> Contractor Title Date <br /> ame.d,P' t)' , _ t <br /> APPhce eck-- pllcab,Cat ryX=7)and Fill in the Required Information <br /> e0 <br /> plea VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> or J y 1, June 30, 19 Disposal Sites — <br /> _Description(Make/Yr.,Color) CAL. License Renewal No, <br /> Serial No. CAL. License 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 R.S.or R.0-E. No. <br /> R.S.or R.C.E. Name Test Date/Time tj <br /> Test Location 6 <br /> q. ❑ SANITATION PERMIT P <br /> Job Address/ oca 'on l.�r <br /> Owner Address <br /> ❑ PACKAGE PLANT <br /> SEPTIC TANK CESSPOOL LEACHING FIELD 11 SEEPAGE PIT <br /> ❑ TEMPORARY �AIEW ❑ REPAIR ❑ HER <br /> E ❑ PERMANENT <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 4;1, <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 Where Certified r <br /> Operator Name <br /> 1 Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> Hameaty�crorficr:esrda�ent's�frJnnturesertfii�str�efo;±o�r�jA "lrcrfifyythatintheferformanceofthetfotkfortiv,iichlltis#3ermit15155ued,lShallnotCmploytlttypCrson <br /> In such manner as is became stzb)ect tcworcntz;i :ampea;ati n vVs of Gatifarriz." <br /> Contractor's Nring or sub-aontra.ti. dgr�atwc-Wortiilos -Ile following: `I certify that in the performance 61 the work for which this permit Is ISsued,10311 <br /> employ persons ssbicct to worksrlan's compensation;llw;of Caiiforni <br /> Thereby certify that I have pr ed this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and. les nd reg ions a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> IS <br /> 3 <br /> FO D MENT USE ONLY <br /> Fee IS DUB: ❑ ANNUALLY _ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 8.Receiv REMITd By uly 31 <br /> BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE C? c <br /> LESS - <br /> PRORATION <br /> PLUS L <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a. Ib 1 O lDenvered <br /> Received by Date Receipt No. <br /> Permit No. Issuance Date Mailed <br /> 1601 E.HAZELTON AVE.,P.O.cox 2009 STOCKTON,GA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ' ENVIRONMENTAL HEALTH PERM ITlSERYQCES <br />