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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE `rB�y <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Hea Is rlct <br /> Business Name (DBA Address C4o(-) 409 A=-7141 <br /> a Owner H&RESAWNfI MC LELLAN Address PtO• Box 4- t,-t, 'FNNi'csTma <br /> J Firm Partners, Addresses and Telephone Numbersc�tv�AQl�i <br /> a Business Telephone No. c ' 'a M Emergency Telephone No. <br /> c ' !IRb .1• tilrsiiop P t� (?-may) 239 -5(21 <br /> Contractor Licence No. 7 533 <br /> Applicants Name (Print) 'AAi_'lFR E C'uk 1 1 M Title Ir- U- G Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information (f S� < i�34> -419�Fln'1"tE <br /> , l <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 40b b M A�N1t'1hi PLAZA (�o�rj�3q--�793CYrt�accl <br /> For July 1, June 30, 19 Disposal Sites tv�y <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 `A`S7"315 PARcE�. B o 4050 t NCIR 'N OV WPRPt cµ tRD RL, <br /> Q.C.E. Name VVA rci G RM IT I RMXaf R.C.E. No. i <br /> Test Location BIP-b PUN t'tENlr_'RACa - CSEE P>"Tr E'!_Aw1 Test Date/Time <br /> 4. ❑ SANITATION PERMIT omu'—' s be <br /> CYF <br /> Srlltat� -1 Its <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 I <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 r() <br /> Operator Name Where Certified �_D <br /> Plant Location 1 <br /> Plant Capacity No. Units Served f <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 signatame certifles theteflowinq:"I certify that in the performance of the work for which this pei mit is issued,I shall not employ any pe <br /> in such manner as to become subject to rrorkrnan'!:cempensaticn laws of Ci,.Nor is ' <br /> Contractor's hiring or sub-contracting ainnatmre csrti-es the fallowing: "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 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> nn <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED d1 <br /> AMOUNT �mm <br /> FEE <br /> LESS f`J <br /> PRORATION <br /> PLUS <br /> PENALTY G <br /> N <br /> OTHER f° <br /> OTHER 7• <br /> My— <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 />