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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Jr (For Non-Transferable, Revocable,and Suspendable) SEPTAL E wF <br /> ENVIRONMENTAL HEALTH PERMIT A4 JV8 2-0 33sG-01 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) L�1/`lNf LOL�/L 1 SNG Address 2825 F, 171YW-7-4,6 Sr,, x-571-/J <br /> a Owner &Y 1-"4C4 h-, S% Address Amt?* 2. 60A Z915--D C'aReN77�«7b G�- <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _-% n iuAo7 I/4i..Anr�.&J2(2� /V, S/Z?�.la 8 <br /> L Applicants Name (Print) JN.J A I 101✓/5 Title �r"s 6&0iO6lST Date <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 n2:5J,r� �J <br /> • -O /0*/ <br /> No. of Chemical Toilets Stored <br /> 3. pERCOLATION TEST <br /> R. or R.C.E. Name /N LZ6N R.S.or R.C.E. No. <br /> Test Location Test Date/Tim r � �� _�_45t <br /> 4. ❑ SANITATION PERMIT ofiapr fLCOLrAva- 76g/ <br /> Job Address/Location <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 /> Home owner Of licensed agent's si9natme certifies thefoNawing:"I certify that In the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's Compensation laws Of Clifomiia. <br /> Contractor's hiring or sub-contracting signsture cerVfies tt+e following: '1 certify that in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to workman's compensation laws 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, and r g and regulation the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X A <br /> FOR DEPART NT 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 25 <br /> d v <br /> Rec6ived by Date IReceipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />