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.. . <br /> Applications Will Be processed When 5ubmitied Proper y <br /> APPLICATION endable} g�pTAGE <br /> FA�plication <br /> (For Non-Transterab .Revocable,and Susp ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE is hereby made to carry on business in the jurisdictional parea <br /> e'o$the San Joaquin Local Health District <br /> r7 0101103 <br /> Business Name (DBA} r ,FL "- Address <br /> aOwner �' <br /> � Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. Date <br /> Contractor Licence No. F Title <br /> W; <br /> L Applicants Name (Print) 1401Please check Applicable Category(1-7) and Fill in the Required Information <br /> ION <br /> 1 ❑ PUMPER VEHICLE PERMIT REGISTRAT (FOR <br /> a S eEHiCLE) <br /> For July 1, June 30, 19 <br /> CAL. License Renewal No. <br /> Description(Make/Yr., Color) CAL. License No. <br /> s <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <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 R.S.or R.O.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> J�c� s«lam <br /> q, XSANITATION PERMIT' <br /> Job Address/Location Address ~� ❑ PACKAGE PLANT <br /> Owner r LEACHING FIELD ❑ SEEPAGE PIT <br /> ) .SEPTIC TANK ❑ CESSPOOL ❑ REPAIR Sop `l <br /> ;• PERMANENT ❑ TEMPORARY,4 J�; NEW <br /> g. ❑ CHEMICAL TOILETS For July,1:,-June 30, 19 <br /> r Type Construction <br /> f l- Disposal Site <br /> (Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> g, 11 PACKAGE TREATMENT PLANT For July 1,- June 30, 19 Where Certified <br /> c Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> ❑ Less Than 1,400 5q. Ft., ❑ More Than 1,000 Sq. Ft. �J <br /> E SIZE: <br /> ❑ PRY CLEANING, Chemicals Used/Amount/Mo. <br /> ( <br /> F <br /> application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this app i Joa Local Health District. <br /> ordinances, state laws, an les and regulation the <br /> APPLICANT'S SIGNATURE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> I1 &Received By January 31 Jell 1 &Received By July 31 <br /> REMIT <br /> Fee is Due: C3 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH January $ AMOUNT DL1E CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> F BASE <br /> EXPLANATION DATE DATE <br /> 1 FEE <br /> i LESS f <br /> PRORATION <br /> PWS <br /> PENALTY I <br /> 3, I <br /> { <br /> OTHER <br /> OTHER + �/ <br /> * r7 G,2e ( s�v Date Mailed Delivered <br /> Issuance <br /> 'e F Permit No. <br /> Fteceiv by ; <br /> ate� Receipt No. - 1601 E.HAZELTON AVE.,P.C.Bax 2009 STOCKT N,CA 952 <br /> APPLICANT 5'F ' RN ALL COPIES TO: ENVIRONMENTAL HEALTIi PERMIT/SERVICES l <br /> a.; I . i -- <br />