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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) S>=PTAGE <br /> P, ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> h Business Name(DBA) a _ Address <br /> a Owner of P�MAI �0 YL (20Q Add ress E �'0 . <br /> J f=irm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - _ A <br /> LApplicants Name (Print) 4E #5411 MO Ile. A' Date 7; "A.2. W <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) i <br /> Serial No. CAL, License No. CAL.License Renewal No. <br /> t� <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2- ❑ PUMPER YARD- _ a <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 /> �,t_ -•..�'�-:ik �, ..\ -a, M �l .Ss:' w, "� .4�' a � !ir - -l'� .''4,` `�i'y�� a <br /> '4. ❑ SANITATION PERMIT' <br /> Job Address/Location -` ' A ^ 7,444, <br /> Owner ' Address ry f II <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 'if SEEPAGE PIT ❑ PACKAGE PLANT <br /> IMPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ~_• <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 /> 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. t r, <br /> ►lam°'""'e�°rl{fidat ps'aslynatwecertifiasthe►oHewinp:"#cercii►yytAaliAtflegt3rlormanceoftheworkTorwhirfrtttisper <br /> in Such Manner as to beceme Subject to workman s compensation lawsofCalifornia" mitisissued.fgT�allnotemplayanypelsafi <br /> , <br /> ContrutoYs h1Ao4 or rrob-eonaset:ng signature gereitries >the sotto�iiiii : 1 oertity that In the performance ottha work far whlEh lA+s <br /> employ Wson6 subject to workmarfg compensation laws of California" permit is issued,!shall <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 rules and regulations of the San Joaquin.Local Health District. 1 ° <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY � - <br /> Fee Is Due: ❑ ANNUALLY ❑=PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By,lama y 31 ❑ July 1 &Received By July 31 <br /> t -- REMIT <br /> BILLING REMITTANCE $ <br /> 'BASE EXPLANATION � �AMOUN3 DUE CHECKED <br /> DATE DATE rREMITTED <br /> AMOUNT <br /> FEE <br /> LESS 11h,e.` F <br /> PRORATION 4 <br /> PLUS ' <br /> PENALTY <br /> OTHER _ - .. <br /> OTHER <br /> Received by V Dat r R ceipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON A .,P.O.3ax 20Q9 <br /> STOCKTON,`A 95201 <br /> rs 7 o�j D <br />