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APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEAL_ H PERMIT <br /> LIQUID 9ASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name(DHA) LF F ALS �%,Lti c�r-- Address <br /> Owner Address <br /> Firm Partners, Addresses an e e hone Numbers <br /> S Emergency Telephone No. <br /> Business Telephone No. <br /> Contractor Licence No.. 1 LA C1 <br /> Applicants Name (Print) V Title Date <br /> Please check Applicable Cfgteg[lflf(1-7)and Fill In the Required Information . <br /> 1. ❑ PUMPER VEHIC E PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, Junp 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 /> r., <br /> 2. ❑ PUMPER YARD f: <br /> For July 1, Ju"30, 18 <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 PE"MIIT Y 4 <br /> Job Address/Location _-_ <br />.Owner— <br /> —51_ R\I 4 ?1 Address <br /> 9 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT .. k <br /> ❑ OTHER <br /> Ff PERMANENT d TEMPOFRAITY „; NEW ❑ REPAIR x k <br /> S. ❑ CHEMICAL TOILETS For July-1,-June 30,19 f �, <br /> Type Construction f i--'"Disposal Site i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,19 <br /> y Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> ' '- <br /> 7, ❑ LAUNDRY For July 1,-'June 30.19 <br /> SIZE: ❑ Less Than 1.000 Sq.'Fl.i': ❑ More'Than i;000 Sq Ft. <br /> ❑ DRY CLEANING,CheAllcels Used/Am ount/Mo. <br /> i <br /> I hereby cert at I have prepared'this application and that the work will be done in accordance with San Joaquin County 5 <br /> E ordinances, state la and rules nd regulati sof the San Joaquin Local Health District <br /> tAPPLICANT'S SIGNATUR I <br /> - FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 13 ANNUALLY PER UNIT .❑ PER SITE ❑'EACH ❑.January'1 6 Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT i <br />` BASE EXPLANATION BILLING REMITTANCE = "S AMOUNT DUE '-CHECKED <br /> t ATE DATE REMITTED -+_AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �`- - •'€ <br /> kf OTH ER .' ''_T'"l'-+`• s- ' .�' -_;" Wit+ y �-' E�r `It <br /> l .OTHER c, �' F r x a.• A.z e'1 Y <br /> Received by Dale -r4; r Receipt^NO r Permit NO, issuance Dale Mailed ,.Delivered i <br /> a <br /> APPLICANT—RETURN ALL COPIES TO,. ENVIRONMENTAL HEALTH PERMIT/SERVICES - 7601 E.HAZELTON AVE,P.OBoa 2009 _ STOG%TON,CJS$24 R <br /> Ffi� a.'µ✓.,; `-z .�1. F s3'• i •> •%S- ;C, _ <br />