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_t <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The APPIicalloft <br /> APPLICATION <br /> (Far Non•TranttlerabM,Revocable.and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEf'T,aGf t <br /> LIQUID WASTE <br /> Application i rely mad to r 4 usin sin esjun tlanal area of the Jos m Local Health District w <br /> �t3usineSs Name[ -N - <br /> Owner Addrs <br /> Firm Partners,Addresses an T I t ne NVbe - -__-___.__ _ �__ -- _ <br /> Business Telephone No. .- �0 -_ _ --_ Emergency Telephone No. <br /> Contractor Licence No. --33L7-�*' ----- - - -- k <br /> p; Applicants Name(Print)_ -__�Title _ -._- ._ Date- =F� <br /> .-.* <br /> Please check Applicable Category(1.7)and fill M the Req Information y 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) s. <br /> For July 1. -,----June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> --- <br /> Serial No. — CAL.License No. w ----- _ CAL.Lkxnse Renewal No. <br /> Capacity - - Gal..Weights S Measures No.- - ---= <br /> Equipment Parking Address-- <br /> 2. <br /> - <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 - --- <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> a `TesVrA,,TAT,O, <br /> ation �.— --- _� Test Date/Time ------- -- <br /> 4. PERMiT <br /> 1 ._ �st_ �dd �Aj <br /> "f Job Adtlress! cation _._ - -------- - --�- A <br /> Owner ,__ <br /> ❑ SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD S. <br /> �AG£PIT ❑ PACKAGE PLANT- — - -- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW . UKEPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For J1tly 1,-June 30, 19-- <br /> Type <br /> 9.-_—Type Construction-_.-------------..._-...._.-.-__.--_. Disposal Site <br /> No.of Units ____--__..-._ -.._...--•- Equipment Storage/Cleaning Location(s) <br /> ,. 8: ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> 69- Operator Name -_- Where Certified ---•--.._.. _-- -.- ---..____ ___. _ r <br /> Plant Location <br /> A <br /> a ' No.Units Served <br /> PlantCrpacity__-_...-.._.,_„.-___.._..___..__.w_-_..,__�_-_._-__._y.� __....... . <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. FI. <br /> ,X ❑ DRY CLEANING.Chemicals Used/Amount/Mo. <br /> I hereby certify that f h the preparers this application and trial the work will be done in accordance with San Joaquin County <br /> Z ordinances,state laws,and rut and regulation 1 Uye San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUAt LY ❑ KR UNIT ❑ PER SITE ❑ EA04 ❑ January t A Rr --d Fly JPmun'y 31 ❑ July I A Rncopved By July 31 <br /> BAS' EXPLANATION i tl1LLING RE4tIrTnNGE ; s AMOUNT DUE CHE`KED <br /> r-+ DATE DATE, - REMITTED ( AMOUNT <br /> I' <br /> PRORATION ; <br /> PLUSPENALTY <br /> . <br /> OTHER { <br /> net'^,v,•h r r Dar.• 'h.^,r+rtu torr�,!'in • IsauanCe UnTw Mndrrl flnry*red <br /> -. APPLICANT—Rr'TUAN ALL COPIES T4: ENVI9101.MFNTAL HEALTH PERMIT!SEAYICES 1601 It HAEr►TON AVE.00 90■r009 STOCKTON.CA 9000 1 i <br />