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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheAppllcauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) $EPTAGE <br /> v_ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE J ✓ <br /> Application is hereby made to carry on busin s irsthe jurisdictional area of the S Joaquin Local Health District <br /> Business Name (DBA) ��� �,� Jb� S 'Address_ :. <br /> aOwnerAddress <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. IV Emergency Telephone No. <br /> _J Contractor Licence No. '" 33 <br /> Applicants Name (Print) T Title ;' Date �h <br /> Please check Applicable Category(1-7)and Fill in the Req re�mation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For-July 1; -- - . June 30, 19 _ Disposal Sites - - - <br /> noo.-rin4inn 1KAnlra/Vr Cnlnrl - ... .- <br /> Serial No. CAL. License No. - - Y CAL. L#ccnse Renewal No. <br /> Capacity Gal:, Weights Measures No. <br /> Equipment Parking Address _ A <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30 19 y <br /> kl <br /> No.of Vehicles Stored s <br /> No. of Chemical Toilets Stored t I <br /> � f <br /> 3. ❑ PERCOLATION TEST s 4 <br /> R.S.or R.C.E. No. I <br /> R.S. or R.C.E. Name !„ <br /> T Test Date/Time <br /> Test Location <br /> ;4. 50 SANITATION PERMIT <br /> Job Address/Location ` ; <br /> Owner �' Address ` • f <br /> ❑ SEPTIC TANK 13 ESSROOL LEACHING FIELD A SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY I ❑ NEW 99 REPAIR $ ❑ OTHER ZtW <br /> 5. ❑ CHEMICAL TOILETS For July 1,i June 30, 19 Disposal Site i A "� # I <br /> Type Construction p <br /> No, of Units s Equipment Storage/Cleaning Location(s) <br /> 6. 11PACKAGE TREATMENT PLANT For July.1, -June 30,,1"9 i r <br /> Operator Name- <br /> Where"Certified <br /> Plant Location f <br /> ,Plant Capacity o:-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 /> Homeownerorlreensedagent's siSnalurt+ rt;fhiatt�efollowing-"leent!ytha±'^the performanceofthe work for which this permitisissued,lshahnot emplayany persals <br /> in such manner as to become subject to wtrrkman'�,cnsupansatinta laws c'{'.^7i;ornia" ,,.�. - r- <br /> ` Contrectar'■ hn or aub caatractinq:sip)nature certifies :bfl iat!Uwrnr#: 'i certify that in the perf6rmance of the tiyvork for which this permit is issued,I shall <br /> employ persons subject to workman's comp <br /> ensation laws of C-alltonila." <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-re ulations o e Sa oaquin Local Health District, s <br /> APPLICANT'S SIGNATURE nn.— 1 <br /> t w FOR DEPARTMENT USE ONLY <br /> f r Tt <br /> Fee Is Due: 11ANNUALLY I ❑ PER-.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31 <br /> REMIT " <br /> ' 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE i. EXPLANATION DATE DATE REMITTED AMOUNT { <br /> LL <br /> (S <br /> FEE <br /> FEE J .. - <br /> LESS <br /> PRORATION 6 <br /> Z <br /> PLUS ! <br /> PENAL-TY €._ (�(/�'���"- r - <br /> OTHER <br /> OTHER <br /> Received by Date 'Receipt N. Permit ND. uan Date Mailed Delivered, <br /> �'" <br /> APPLICANT RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E. ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />