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AVplications Will Be Processed When Submitted Properly Completed. BeSureTosign Ine %ppllcanon. <br /> y APPLICATION <br /> 3 (For Non-Transferable;Revocable,and Suspendable) t:-SER74GE <br /> ..r,. ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> i <br /> Application is hereby made t car on business in the'uris ctional area of the,Aan Joaquin Local BaltDistrict <br /> �8usinessName (DBA) C diet & e Address—R0, 13d& ?� `��� I <br /> y Address F,ID *ix�� <br /> a Owner <br /> Firm Partners, Addresses and Telephone Numbers ftp_ S <br /> Emergency Telephone No: 7�^�J <br /> CL Business Telephone No. - <br /> Contractor Licence No. <br /> -Title �121 /p -. Date <br /> L Applicants Name (Print) ' <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 cs Disposal Sites - <br /> Description(Make/Yr.,Color)_ <br /> ! <br /> Serial No. <br /> 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. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 11111 11 U .7 5 z1� Ci (� <br />( Owner L V' � Address Q <br /> f SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 0 REPAIR SEEPAGE PIT ❑ OTHERPACKAPLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <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 /> Where Certified <br /> Operator Name 4,1 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> orso'" <br /> }tome owner orlicensedagent's signaturecertifiosthafollowing:"!certify that in the performance of the work for which this permit is issued,I shat!not employany p <br /> in such manner as to become subject to workman's compensation laws of Caktornla.' <br /> ll <br /> Contractor's hiring or sub-contracting 'signattAre certifies the-.following'. "t certify that in the performance of the work far which ibis permit is issuetf.I sha <br /> ll <br /> employ persons subject to workman's compensation laws of Ca!itornia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> h ordinances, state laws, and rules and regulations of tho4an Joaq ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FAIL- � �' <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 /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS R <br /> PRORATION / <br /> PLUS �— <br /> PENALTY - .. <br /> OTHER „- - - <br /> OTHER <br /> 14 <br /> Received by D to Receipt No. Permi No Issuance Date Mailed Delivered <br /> 1801 E.HAZELTON AVE.,P.O. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Box 2y1/1,9�9/ STOCK ON�CA 952fi1 <br /> fa�'L'v+aG-r SJJ <br />