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FFFWApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ` APPLICATION (� <br /> W,U -131 (For Non-Transferable, Revocable, and Suspendable) SEPTAG:' I " <br /> 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 /> r Business Name (DBA) /Address <br /> z Owner L�G/7/7 � /'�A��G/7Z Address >a .4e:V0 <br /> Firm Partners, Addresses and Telephone Numbers <br /> gsz Ifo <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. ��i,r <br /> Applicants Name (Print)�Woi� TOSC`j Title e"11.11 4.,a°tC/' Date �yA- `y•z990 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Sfotrl�� '9rSFo <br /> For July 1, June 30, 19 Disposal Sites ���-;do� <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. of Chemical Toilets Stored - <br /> 3. .1 PERCOLATION TEST <br /> Rr6. or R.C.E. Name 1111140.-,eq-R.C.E. No. �G <br /> Test Location _— Test Date/Time <br /> 4. C1 SANITATION PERMIT '�' /�rho <br /> Job Address/Location i <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 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 /> Homeowner or licensed agent's signature certifies thr.fr'l!ovving:"f Certify that in the performance of the work for e;hich this permit is issued.I shall not employ any person <br /> in such manner as to become subject tri wkm^n or =::.; toeF alit^';�:� if fa-!# <br /> Contractor's hiring or sub-contractinG s'gnacare c< fi les :are fafbwrng: I certify tIW,in the perfor111ance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation iaws of California" <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, art rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 7-�.e�. <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 $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 0 v <br /> LESS c7(7 <br /> PRORATION J <br /> PLUS <br /> PENALTY CTD <br /> OTHER <br /> OTHER <br /> 97"� <br /> R e c 4r AtF1bate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLIC T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />