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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Ap idn" v <br /> APPLICATION RE ,V-v `1� j <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAG 1g�� l (t/j <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE AVN N�A`NEP��N <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Dis <br /> ,„Business Name (DBA) 0awr7l;nah £ Piazzn Address 323 W atm �E� <br /> aOwner G1 '4aurn.bQC," Address 5c1rr3e <br /> Firm Partners, Addresses and Telephone Numbers Te 1rry PL _-z_,-i <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) — �-� e +�. C• 6 Date1+ -2-4.47 <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. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name ta-11 I . $ate T b 4 cam`{ R.S.or R.C.E. No. Z <br /> Test Location Test Date/Time j <br /> 4. ❑ SANITATION PERMIT MIUL -7- 7 <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 /> ❑ DRYW.&y 4WWJArPhemiCals Used/Amount/Mo. <br /> censedagent'ssigneturnnertili^sthefMfotyin4 "Irprtif ihatir,ih r <br /> in such manner as',a become sub;ect ;'r.„ ;; ., •, y the work frr which this permit is issued,I shall no to a <br /> Contractors hiring or sub-enntractino sig lnlli:rr.,.U!,�0 �1 if,r;1i:' p y r pers9n <br /> e 4natura_ cert Cali the fa:cwG;y: 9 GEttiiy that in the Performance of the work for which this permit is issued,I shall <br /> �DIoY Persons subject to workman's compensation lan 9i iafiiornia." <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 ruj1A and regulati ns of the San Joaqu Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received B my 31 <br /> RE <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE <br /> DATE DATE REMITTED <br /> MOUNT <br /> FEE c, SO-00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receive by Date Receipt 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 />