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<br /> Applications Will be Processed When Submllbd Property Completed.rt Sure To Sign The ApplIcallon.
<br /> APPLICATION
<br />_ - (For Non-Transferable.Revocable,and Suspendible)
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application t h reby m de to car on business in the'urisdictional area of he San Joaquin Local Health District
<br /> Busin"
<br /> Nam (ORA)PA A� �I>} �/ +�.�NSr r Address��X�k I4s S- 1 _Q_9sto-1--
<br /> i Owner Address
<br /> Firm Partners. Addresses and Telephone Numbers
<br /> Business Telephone No. 4642'9CIV7. __. _ .._ _. _- Emergency Telephone No
<br /> Contractor Licence No.- 1574---3 - --------- -- - --w-,� - - ----- --- - -- - -
<br /> Applicants Name(Print) �.l.- Y%•-w*I S_. .- _ Title 1"L�.� �__- Date ZS=BZ-..
<br /> Please check Applicable Category(1-7)and Fill in IM Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE)
<br /> For July 1, . June 30, 19 Disposal Sites ___--
<br /> Description(Mal'&/Yr.,Color)
<br /> Serial No. .. _-.. CAL.License No. CAL.License Renewal No.
<br /> Capacity _-- _.- _ _.___ Gal.,Weights d Measures No.--___-__-•-----_----_---.-.-_- --..___..- --.-� -- --_--
<br /> Equipment Parking.Address
<br /> 2. ❑ PUMPER YARD
<br /> For July t,____.__. 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.Z .E.No. _ 4 -
<br /> S Test LocationI ` I
<br /> Test Date/Time
<br />_ 4. X SANITATION PERMIT
<br /> Job Address/Location Z Z2 Z Z tb. CJ u7 1VL
<br /> R� O ner f 0_V__1tAc_QAC_0 _ Address_ sb?�pC��(__S.eT9S{��G.f✓vL 175. tC�4-•- -5`L'.Z�
<br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD OSEEPAGIE PIT ❑ PACKAGE PLANT
<br /> Air-PERMANENT ❑ TEMPORARY XNEW rtEPAIR ❑ OTHER
<br /> t>R S. ❑ CHEMICAL TOILETS For July 1,-June 10, 19
<br /> Type Construction ....-__-___-_-_,-_ -_ DispOsat Situ
<br /> No.of Units Equipment Storage/Cleaning Location(s) _--S. ❑ PACKAGE TREATMENT PLANT •f.Dr July 1.-June 30, 19 .-
<br /> Operator Name Where Certified ---.----------_-.__-_�---__-_
<br />(» Plant Location
<br /> A
<br /> Plant Capacity --- -- .._-� __—_. .-. No.Units Served ___-- -_---------,_-. --
<br /> 7. ❑ LAUNIIRY Fu. July 1,-June 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq.Ft.
<br />%Ft'I ❑ DRY CLEANING,Chemicals UsedrAmount/Mo.
<br />��. Nmm�nwnm�•ti:rn•...i nrrrta eb!n�••,rr'.cnr•i!int :Nrl Ir i. '�y;'`� •n, .. .rCc u'I'•? k Y. th'h.. f:fiil iSiSS4Pl'. ;h;' .,,aT'11?'/'^�!! `...
<br /> '' i'1!.un!,In . �.c:••,. , •t,:.,�•F.nl�n, tli r;•1 i t r Pf !t t;.!
<br /> Cnntrorter t hhinq or n,,;nth!n, c-jrtities the Inilnw.ng: I C-I:'.,"1NI in the pC':f.11'mu ut''e:fork In: :t:t^c I mit I;!.`,•L^A,I S!taa
<br />�,, CmFtu1 7^. ""S.uDilt.t lu N. k ! >-.u•!p't».�,l. iw_ul:,dli, c..,
<br /> qq,�xi4
<br /> t�4 „ I hereby certify that I have epared this al ication and that the work will be done in accordance with San Joaquin County
<br /> ordinances,state laws, r end regula S' sof the aq t HS/Ith District.
<br /> 1Y i+
<br /> iy tl APPLICANT'S SIGNATURE X -\- - .. — R --- --------
<br /> cliI\ %
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT 0 PER SITE _❑_EACH ❑ January 1 a Received By January 31 ❑July I A Roes By July 31
<br /> - ---._. -- REMIT \
<br /> �Q. t — • - --_---- BILLING REMITTANCE Z
<br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED
<br /> 7
<br /> .t
<br /> ti AMOUNT /. .r
<br /> a FEE r✓ : �i�`
<br /> LESS
<br /> PRORATION
<br /> PLUS t
<br /> " NFNAI TV
<br /> r'. OTHER -
<br /> OTHrR
<br /> y
<br /> _. .... _.._P . . - __ _._._ ..-------'---- -...._. .._. --.-_ .
<br /> W.•c,•,Ld-nv Dam Rrce! t No ----- PMmd No luuance Date MeiIeci Del,
<br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMFNTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Don 260 STOCKTON,CA"201 -
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