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APPncanons nm Be Processed Who" Submitted Properly Completed. Be Sure To Sign The Application. T <br /> APPLICATION <br /> (For NOh•Translerabie, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i LIQUID WASTE <br /> Appllrauon i Exeby mase t0 r on business In the jurisdictional area of the SBn JoaqQ��In Local Health District1 <br /> I 19esiness Name (Of- - t/ e . Address (-61. LS�Y' ?OS' f /.Pi.I,rPA <br /> Owner_.__ Q Al tf _ --- Address_ / 9_ �e Oy <br /> u Firm Partners. Addresses and Telephone Numbers -- <br /> iBusiness Telephone No, 7.� 5-7�o Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title _��/�_[r Dale <br /> Please check Applicable Category (1-7) and Fill In the Requited Information <br /> i. ❑ 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. Lice.M"No. _ _ CAL.License Renewal No. _ <br /> Capacity Gal., Weights d Meaaurea No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ---For July 1-, June 30. 19 <br /> No.of Vehicles Stored _ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ <br /> R.S.or R.C.E. Name _ R.S. or R.C.E.No- <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT ? q� //,, rn / <br /> Job Address/Lo bon �eIi �_ ASd_/S�7 �•-` �^�f <br /> rDwner . nrf /�. LLu r< --.._ Adgress tI4 �iy �O� �✓+-t t„ s - --- , <br /> �+ SEPTIC TANK ❑ CESSPOOL �.LEADf11NG FIELD ❑ SEEPAGE PIT ❑ PACKAG PLANT <br /> �!I PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR JR OTHER( SLIS" <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> t Construction _ Disposal Slle <br /> W of Units Equiprineni Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name .— Where Certified <br /> Plant Location <br /> { <br /> Plant Capacity No.Urdla Served 1 <br /> 7- ❑ LAUNDRY For July 1, -June 30, 19 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRV CLEANING, Chemicals Used/Amount/Mo. `{ <br /> (I <br /> I hereby Certify that 1 have prepared this appflcatlon and that the work will be done in accordance with San Joaquin County <br /> Ordinances,state laws, d rules and regula lens DI the San Joaquin Local Health District <br /> APPLICANTS SIGNATURE X'% _ — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja <br /> _ . naarY 1 a Recelwd By January 31 ❑ July t 8 RecnreC BY Jury 31 <br /> BILLING REMITTANCE REMIT - <br /> 9ASE EXPLANATION TE <br /> DATE REMITTED AMOUNT DUE CHECXED <br /> FEE AMOUNT <br /> 7 <br /> LESS <br /> PRORATION <br /> PEIPS <br /> EN <br /> PENALTY t -- <br /> OTHER _ -- <br /> 4A"LI4CANT-AVK% <br /> DalReceipt No. Permit No. ka.2 ONl COPIES Tb. ENVMONMENTAL HEALTH PERMIT/$ERVICIS list E.H12ELi0N�V[.,P.O.am=aper aTOGR70N.cq Yi20f 1 <br />