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lereo. or± <br /> Qw— <br /> en Submitted Properly omp <br /> ppplicatlons Will Be Processed Wh � <br /> APPLICATION <br /> n (For Non transferable, Revocable,and SUspendable) $ p�AGE <br /> ENVIRONMENTAL WASTE <br /> HA TE TH PERMIT <br /> ` <br /> ' tion is hereby de to carryon business'n the' risdictional area 5 the 5a oaquin�-Gal Health District <br /> Appllca Add <br /> F Business Name (DBA) Address <br /> a Owner <br /> '7-ts yc:R o <br /> a Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. ►z 3- 9 ? <br /> 2 Dat <br /> Contractor Licence No. 11 <br /> - Title <br /> Nay�e(Print) <br /> Applicants, ,. <br /> Applicable Category (1-7) and Fill in the Required Into oration <br /> Please c4eck <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) " x- <br /> Disposal Sites _i <br /> � * _Ju 30, 19 - V <br /> For July 1, . <br /> Description(Make/Yr.,Color) L.-Licz.,se Renewal. No. <br /> GAL. License No. V; <br /> Serial No. <br /> � <br /> Capacity Gal.,Weightsr:.&Measures No. <br /> - _ '•- r <br /> -Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 #t4,v <br /> No. of Vehicles Stored <br /> d „ T - <br /> No. of Chemical Toilets Stored Ii <br /> 3, ❑ PERCOLATION TEST R:S-or=R.C.>=.=No• - - <br /> R.S.or R.C.E. Name <br /> s Test Dat Time <br /> Test Location 1� <br /> 4. �SANITATiON PERMIT <br /> F Job Addiess/t cation [�J��� IN <br /> Address '"�" � <br /> O 1ner 1 Cl ,PACKAGE PLANT e <br /> ❑ CESSPOOL 1 EACHING FIELD SEEPAGE PIT ❑ OTHER. <br /> ;SEP;IC TANK /NEW ❑ REPAIR - <br /> yyC�f PERMANENT ❑ TEMPORARY <br /> 5 ❑ CHEMICAL TOILETS For July 1,-June 30, 1Disposal Site .. <br /> Type Cionstruction <br /> Equipment Storage/Cleariing Locations) <br /> No. of Units <br /> f <br /> 6- 13 :PACKAGE TREATMENT PLANT For July 1, -June 39' Where Certified <br /> Operator Name <br /> Plant Location J� No. Units Served <br /> I Plant Capacity <br /> ❑ LAUNDRY For July 1,-June 30, 19 r <br /> 7' , ❑ More Than 1,000 Sq.,,Ft. <br /> ❑ Less Than 1,000 Sq. Ft. l 1 <br /> i SIZE: � - - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. s <br /> E <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and rul '`a�egtions the n Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE . <br /> I <br /> [ FOR DEPARTMENT USE ONLY <br /> t ❑ January i &Received Ry January 31 ❑ July 1 &Received.By July 31 <br /> P REMIT <br /> IFee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EACH $ AMOUNT DUE CHECKED <br /> i BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER e' <br /> Issuance Date Mailed e r <br /> Receipt No. Permit No. ST CnKT01ly A 95201 <br /> .'Received by <br /> Date 1601 E.'HAZELT NAVE.,P.O.Box 20491 <br /> -APPLIGANT�RETURN ALL COPIES774e —TO' -ENVIRONMENTAL F4EALT IT,SERYICES �,�� <br /> a <br />