Laserfiche WebLink
(Tor NOft-T•�nafrrabfr,Rovacn0lP, rnr Sr,tnrnr�'ie) <br /> r; 4V)RONMEN"T AI- HEALTH PERMIT <br /> Ltouro WASTE <br /> yr tl Y-"..r •:Or �,.,r•, rr.r l,. �,r.,il,N r.I •h. i..�.,v; i I I:.,,IIS`[)•".1• <br /> r� fit G `i C <br /> i e .d• ,�.` �Y L -;/ Ad�-d�r�r�t�ys• ��r ta'/� //���,/c //J�j/ <br /> 77 �' <br /> j�f!.J Eme-gnncV Trlephn•,r No � L <br /> ..,,••tN V�� �f`� c f!� Ti11.. RJCty A-tr D.Tir' <br /> r Appflc-•�-!, Cr.•egory 1'-7)end Flli n the noquir+d f llormellOn <br /> r't)M•rFF1 VEHICLE prgfalT REGISTRATION 'FOR EACH VEHICLE) <br /> ter h-'G'+^:.tl <br /> ;;AL License No CAL Licenar Renewal No <br /> Gal.Wrights 8 kl"•Isures <br /> •'I r„7M II'rJ <br /> ❑ rUMPER YARD <br /> 1 U PERCOLATION TEST <br /> 11 or R 1�E Nam, R S.or R C E Nr. <br /> •'.l L(calrn" Test Datr Time `— <br /> •T ❑ SANITATION PERMIT <br /> JM- AaAtp:'.% ITOCalton ,,� �� <br /> r)•Afner C'La" <br /> f4C/ao/Y�`-stry.+-rf. ' Address /���' �11� �J( Le <br /> G;SEPTIC TANK ❑ CESSPOOL G-CEACHING FIELD G SEEPAGE PIT ❑ PACKAGE PLANT �} <br /> ❑ PERMANENT ❑ TEMPORARY Q-f4EW ❑ REPAIP Q^OTHER S<--PO <br /> 5. ❑ CHEMICAL TOILETS For July 1 -June 30. 19 <br /> type Constriction Disposal Site <br /> Nr_, (,f Umts Equlpmant Storage/C4:'lning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 <br /> Operator Name Where Cemfied <br /> V'ant Location <br /> Plan;Capacity No Units Serv.M <br /> 7. ❑ LAUNL)Rv 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/M0. <br /> I hereby Certify that I have prep +�th,� apoi on and that the work will be done In accordance with San Joaquin County <br /> ordinances.state laws.and r %, `reg:A�Wnrt Joaquin Local Health District <br /> /i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT L,A,VER SITE ❑ f ACI, ❑ J.1 -V I d R�` ••�Orpe Ry ian,r,v�J ❑"ily t a q ^—1 r+y July 31 <br /> REMIT <br /> RASE FkPl 4NATION KILLING nEMItTA.., % AMOUNT OUE CHECKED <br /> OATF OATF, REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION , i1 <br /> PLUS 1y[ - <br /> PENALTY ` y � <br /> OTHER / <br /> + r / <br /> OT VER I 1'/`/ <br /> Rocrwa' •y Us1.• Prcr�pr N/ .'--t 14" Issurnce Date MArle.1 [N• rr O <br /> - APPLICANT—NETUrIN ALL COPIE3 TO: FNVIRONMFNTAt HEALTH PFPMIT,SL'RVICE4 11101 E NAZE•.TON AVE.,P 2001 TOC Oq,CA 11101 <br /> _. c� f i, <br />