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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' 'eR174 ' (For Non-Transferable, Revocable,and Suspendable) cr- - <br /> a PTA.: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 /> y Business Name (DBA1 acitim bo<h g P4.CLzzq Address 323 a)I, fa <br /> a Owner_ s - Address 3Z3 uj &1m Lod t Co. , <br /> Firm Partners, Addresses and Telephone Numbers '54aM <br /> 5. Business Telephone No.CZOCt ,J 3 i;$ LPA Emergency Telephone No. <br /> Contractor Licence No. <br /> r p �,_ _ Civil rnNr�h Date <br /> �Applicants Name (Print)�.+*L:T',.�" ' Title <br /> Please check Applicable Category -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 (lam <br /> No. of Vehicles Stored ` pl <br /> No. Chemical Toilets Stored <br /> 3. PERCOLATION TFQT <br /> R.S. or R.C.E. Name Z`-) R.S. or R.C.E. No. <br /> Test L cation Test Date/Time�t 1(9 7 <br /> ;**SANITATION PERMIT c�ulz4raJcx�ir NI;S y ,��, - 3 <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 /> Homeo"er or licensed egent•s signStutOORTMiesthsfnilowing:'9certify,fiatintheperformance of fhework ftr whirh this permit is issued,I shall not employ arty person <br /> In such manner as to become subject to workman's compensation laws of Cairtornt, <br /> contrectbes hir" or sub conencting siyniii ts.tifies the fotbwins, i certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation Iaw3 of Catitornia:' An, <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with auin Gdfu1fr5�'"_ <br /> ordinances, state laws, an les and ' ns of the San Joaqui Local Health District. <br /> APPLICANT'S SIGNATURE X C <br /> FOR DEPARTMENT USE ONLY V <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED C-AM.,gkU NT <br /> FEE v O <br /> LESS 4 P 1 <br /> PRORATION <br /> PLUS ^ �� <br /> PENALTY <br /> OTHER <br /> OTHER NXN M S9`1 <br /> 41- <br /> Ref ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />