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.. .. ._. rr __ <br /> Applications Will Be Processed When Submitted Properly omp e e , <br /> _ APPLICATION <br /> (For Non-Transterable, Revocable,and Suspendable) SEP7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> uquln WASTE <br /> 76 7 <br /> Application is erebgmade to carry on busi ess in he juris 'ctionalAdrdressthe San Joaquin Local Health D��trict <br /> � <br /> yBusiness Name (DBA) Address <br /> zOwner <br /> Q J <br /> Firm Partners, Addresses and7elephone Numbers Emergency Telephone No. 1 <br /> 0. Business Telephone No. 2 A",— F <br /> Contractor Licence No. Title �'��' Date <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } <br /> June 30, 19 Disposal Sites 1 ; <br /> For July 1, .. '. _ . .- <br /> Description(Make/Yr., Color) x CAL. License Renewal No. I <br /> i "CAL. License No. <br /> Serial No. t <br /> Gal.,Weights & MN <br /> Measures o.` <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD y •,t �4 -' ' ' R <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Storedk <br /> I'. <br /> 3, C1 PERCOLATION TEST R.S. or R.C.E.No. t <br /> R.S.or R.C.E. Name Test Date/Time 1 <br /> 4 Test Lp6ation <br /> 1 4. SANITATION PERMIT �� <br /> Job Address/Loc tion Address <br /> �� ! 71 �� <br /> ❑�, TH <br /> fP��.KAGE PLANT <br /> r Owner ❑ LEACHING <br /> FIELD � SE PAGE PIT Ly` )ER {,tir>�¢� �j) - 1 <br /> r [9-SEPTIC TANK ESSP OL 11NEW & <br /> REPAIR TF1 L+� / <br /> i L7 PERMANENT ❑ TEMPORARY <br /> -. <br /> 5. ❑ CHEMICAL TOILETS For July i, -June 30, 19 <br /> •;� Disposal Site <br /> } Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units v <br /> i <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1,-_June 30, 19 Where Certified od - <br /> a Operator Name <br /> Plant Location No. Units SL-+s.� T <br /> erved <br /> Plant Capacity q . <br /> I 7. ❑ LAUNDRY For-July 1, -,June 30, 19 t <br /> SIZE: , []'-,Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,-Chemicals Used/Amount/Mo. . <br /> Sys w[-S i�i �► ti- �` <br /> K1z <br /> C red this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that l have prepared Joaquin Local Health District. - <br /> ordinances, state laws, and an roles a d regulationns of <br /> r <br /> APPLICANT'S SIGNATUREX <br /> FOA QEPARTMENT USE ONLY <br /> ❑ January t &Received By January 31 r❑ July 1 d By July 31 <br /> B Receive <br /> REMIT <br /> 4 Fee Is DUE!: ❑ ANNUALLY, ❑ PER UNIT ❑ PER SITE EACH REMITTANCE $ AMOUNT DUE CHECKED <br /> BILLING REMITTED AMOUNT <br /> BASF EXPLANATION DATE DATE <br /> FEE <br /> LESS ,� ��� <br /> y PRORATION A�` <br /> PLUS K Q 1 <br /> PENALTY <br /> s. i. lti <br /> OTHER <br /> l <br /> OTHER <br /> k j O �)-33 ssuanc Date Mailed Delivered <br /> Receipt No. Permit No. <br /> A ,Date 15U1 E.HAZELTON AVE.,P.O-Box 2009 STOGKTON.-CA 95201 <br /> Received 4y' ` <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT—RETURN ALL COPIES TO: moi. jy <br /> �e,t►�e �_ _ I <br />