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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 2 APPLICATION <br /> (For Non-Transferable, Revocable, and Susp,"dable) S�pTAGE <br /> )(3 - 97D- <br /> ENVIRONMENTAL HEALTH PER'' Tm1' l <br /> LIQUID WASTE iJ <br /> Application is hereby Made to carry on business in the jurisdictional area of the Sanjuin oval Health Dist ict <br /> OF Business Name (DBA) U���t� Address `r <br /> aOwner � �,+ ��_r%Q Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. !�R Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) 2f Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <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 /> 5 <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 k <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> .y <br /> Test Location Test Date/Time <br /> 4. fi( SANITATION PERMIT _ �] <br /> Job Address/Location .�- kip f G c t\ <br /> Owner Address LT 677 ce, " 1 <br /> 14 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD x❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ti4 REPAIR ❑ OTHER <br /> 5. 0-CHEMICAL TOILETS`For July 1,-=June 30,-19 - 'c- <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 f <br /> i �- ! <br /> Plant Location ' <br /> Plant Capacity - No.J Jnits Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -- <br /> t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. -, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Holneavinwerlicensed agent's signature r4artlf!rsthe following:"1cgrtirythitisthePerformancr.of*hBworkforwf' ]ILI is permit is i5ued,1shallnotemployanyparson <br /> in such manner as to become subject to workman's cosh nsst+Cn taws 3f Cs#ifnrrda" ;� ) t - - <br /> Contr-w's hiring er su6aorrtracting sit#mat+,re certifies the fc,ttowing: "I certify that in the performance of the WArk for which this permit is iSSited,I shall <br /> empfay petsons subject to workman's comgeasation laws of California" <br /> hereby certify that I have prepared this application and that th6 work will bt3 done in accordance with San Joaquin Courity <br /> ordinances, state laws, and rules an regul ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X e F <br /> FOR DEPARTMENT )SE ONLY__ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' , ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> v REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> J BASE EXPLANATION - -� <br /> DATE � DAIE REMITTED AMOUNT <br /> J ti <br /> FEE I <br /> 1 <br /> LESS / <br /> PRORATION � t <br /> PLUS J' ? <br /> PENALTY <br /> .OTHER Ile <br /> r <br /> OTHER <br /> �-- 16J ,--q - <br /> Received by Date Receipt No. Permit No. Iss once Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Bow 2009 STOCKTON,CA 95201 <br />