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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> -Mor Non-Transferable, Revocable, and Suspendabte) SE PTAG-E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name IDEA)�vfADARRI P1—Se$t • k BaGIE og Address 645 )?i t�;'9�)"3 ,ane <br /> iOwner _ m --- M6 Do nal d. Address <br /> Firm Partners. Addresses and Telephone Numbers <br /> n' Business Telephone No. <br /> < 4-��-8��7 - Emergency Telephone No. 957-4027 <br /> Contractor Licence No. --1 3 362 �. <br /> <Applicants Name (Print) T- R_ Mn.Dn nal A Title Owner Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information C <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) — <br /> Serial No. CAL License No. CAL License Renewal No. <br /> Capacity - Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. Q PUMPER YARD <br /> For July 1, Jurie 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 1 - R.S. or R.C.E. No. ' <br /> Test Location Test Oate/Time <br /> 4. ❑ SANITATION PERMIT •!� ' 9 7 <br /> Job Address/Location L ✓� ^w <br /> _ Z <br /> Owner - Ad I''I�,��� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING IELD SE AGE PIT •--LRAC14AGE PLANT O <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR _❑ OTHER (` <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �— <br /> Type Construction Disposal Site <br /> No..of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. 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. rr <br /> -- f <br /> 1 hereby certity 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 r - ns of the San Joaq ocal Health District <br /> APPLICANTS SIGNATUREX� ; <br /> - - FOR DEPARTMENT USE ONS <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jamury 18 RecenW 11Y JMRrry 31 O JuTyT►Reswee ftl,*71 <br /> REWT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUPWIDUE -jCNECKEI] <br /> DATE -DATE REMITTED';,',.: '-.j-�_.•. AAR7INT <br /> FEE <br /> LESS lam_ <br /> PRORATION <br /> PWS / Lys <br /> PENALTY //Yd / <br /> OTHER <br /> OTHER <br /> Recelvea oy oate Receipt No. Perm.I No. ua a ate Mailed DalivereE <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 N AVE.,P.O.Box 21109 STOCKTON,CA 9SM1 <br />