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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1 - APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendabie) SEPTA(- <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 /> OF Business Name (DBA) , AIMIq. rYre.LTS��51 - Address ?127 • ©�''y F�csr3yIOZ <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> o. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. -7 <br /> Applicants Name (Print) Title Date / 9^&2F <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. A PERCOLATION,jEST C t✓�i'e�d�r� <br /> R.S. or R.C.E. Name !\on ��-�iI iw 2 E✓1 R.S. or R.C.E. No. 2-19 ZES <br /> Test Location N' r0i4o9d Tes Date/Time <br /> 4. 11 SANITATION PERMIT 2 �S T' /0ZtTP� <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 11 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeownererlicensedagent's sigllaturecartiftesthe foltowing:"Ice yyt at1nt eperformanceo t.ewo orw IC this permit is issue shall no employ any p r, <br /> in such manner as to become subject to workman's Compensation laws of Califcrni' " <br /> Contractor's hiring or sub,-contracting signature certifies the foNowing: 'i certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workmans compensation laws of Calitornia.'• <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 d re lationns the/pyan Joaquin Local Health District. 7 / <br /> APPLICANT'S SIGNATURE A�� // /_te__� 7� <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 <br /> .AMOUNT <br /> FEE 'to <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Zl,�? �- -19 <br /> Received 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.Boz 2009 STOCKTON,CA 95201 <br />