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APPLICAtION� <br /> _ (For Non-Transferable, Revocable, and Suspendable) SFPTAGF. <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the Sap Joaquin Local Health District <br /> V) E�ItsmPst NAme (DBA) /�rith -� ��J. .► ! —_. - - Addiess-k-AIL-4, 14 )"o Ck t. <br /> 5 <br /> 4 Owner 444+ _L._ £fit, s �oG _ Address/J05 7XI' ✓Te 0-0,•$vrrc 14 s4z,29.»�.y7U__ _ <br /> �— t- -- <br /> zu Firm Partners, Addresses rind Telephone Numbers _ <br /> a Business Telephone No. - Oq `f7Z - /U9/ _ Emergency Telephone No. <br /> � <br /> Contractor Licence No. <br /> - ---------- - -- - <br /> Applicants Name (Print) PILig, - - - - 72 <br /> Title . � � Date � �� <br /> Please check Applicable Category(1-7)and FIII in the Required Information <br /> 1. ❑ 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. License No. CAL. License Renewal No.-_.___-__ _- <br /> Capacity " s;_ _ Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, r June 30, 19 <br /> No. of Vehicles Stdred <br /> No. of Chemical Tbilets Stored <br /> 3. A PERCOLATION TEST <br /> R.S.or R.C.E.NarHe NEr0 <br /> c. . Ar4g1re-<o l — R.S. or R.C.E.No. <br /> Test Location _WTy 4-OCV5 T Lops Test Date/Time �� tsi /19c� •- �s r'��r <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For,July 1, -June 30, 19 <br /> Operator Name I Where Certified _ <br /> Plant Location -� _ ----- - ------ ----- _ . - - - <br /> Plant Capacity _ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -JUM6 30, 19J—__- -. - ----- -- _ <br /> SIZE: ❑ Less than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home ower or licensed agent's Nanetitre oertHklsth�following:"1 cert!fr tHM I�the Iterfnrrmance of thr work.for which this permit is 1ssuad.l5hall not employ any person <br /> in such manner As to become suhjee to wcrkm, --r-etn;leneati>n 151;5 gE c;itt, <br /> Contractor's h) or avb-c,ntruefinf, signatrrvr :e,:f.,• `1: b,Norring. i Certify that In tim performance of the work for which this permit is issued,I shall <br /> employ persons subject to workrla;i s ccmpensarias <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Jonquin Cnllnty <br /> ordinances, state laws,an ules and re y <br /> lations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY d PER,UNIT ❑ PER SITE ❑ EACH ❑ January 13 Received By January 31 ❑ July 1 b Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASte EXPLANATION DATE DATE REMITTED AM T DUE CHECKED <br /> - AMOUNT <br /> FEE r l oG�oo � ,�-Y v� 3�9a --wG.o�- - -- - ( . 7 <br /> LESS <br /> PRORATION <br /> PLUS --- --- --- ---- -- - <br /> PENALTY <br /> OTHER <br /> OTHER -- — ---- <br /> by nai� <br /> �.d - 116- <br /> ------ <br /> R ce Fdecoipr-tJA-- Permit No Issuance Date Mailed Delivered <br /> ---- LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 -- <br />