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Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign The Application. <br /> APPLICATION <br /> (For Non-Transtera-le,-P.evocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb made turisdictional area of the San Joaquin Local Health District <br /> Business N e (DBA) FR 1' lLS Addres ,`rte E LO <br /> i owner FIR Av. A dr s �-���� - �-��� T Cf- r SUMO/. CA <br /> Firm Partners, Addresses a Tele one Numbers RZ 3 0'7 5 <br /> K Business Telephone No. flG 3 —�1 Emergency Telephone No. <br /> 11 Contractor Licence No. ^ _ <br /> Applicants Name (Print) �o G e Cr1 Lt lS.C1C� e-'ALM I : T ills Ove E� Date 3Q� <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) <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. o�fy(�]��••emical Toilets Stored <br /> 3. I PERCOLATION TEST p�9 p�C�E <br /> R.S. or R.C.E. Name T G1kt&N <br /> Test Location Z5 rt. LONE-CREW - SGAIO tJ 1 est Date Ime <br /> 4. ❑ SANITATION PERMIT `\ <br /> Job Address/Location �1 <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ 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 l,.-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> Nome owtterorlirwntted Itlienl'siipnaeere txrdriisMaTolflsw�ing:"1 ceM1that In Lheperformance of th^,vcrk forwhlch this permit is issded,I shall not employ am/Person <br /> In such manner as to become subject to workmar's compeosarietl lays o!C ity temk <br /> Contractor's h;ring or wb-contractinc sinnatwo -en:' � '4kWWB: i cKtNy titgr in tits pertirmince alHle-wel'k for w"tills permit is Issued,l shall <br /> empiop ermn oeo;2ei to wcrkntads colnpenseliou lass of Ga!tb�IV: <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 lavit and r d regulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE < _ �' � ' — Qs-EIZALD 7�kC�P, <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 /> BILLING REMITTANCE $BASE EXPLANATIONNPATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 'l <br /> PLUS I OO <br /> PENALTY <br /> OTHER <br /> OTHER <br /> (YID -' 9 i z6 L7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PnIAIT/SER1iiCES 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKTON.CA 95201 - <br />