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APPLICATION <br /> r Non-Transferable, Revocable, and Suspendabl <br /> �-ENVIRONMENTAL HEALTH PERMIT NiaW `"cTF't`r <br /> LIQUID WASTE <br /> Applicat"on is hereby mad to wry o busine In the jur'sdlctional area of th an Joa uin Local H Ith District <br /> „Business Name (DBA) l_ \��L� �\AC- �+ r=Address J(�qt ).__1 (�\ i�C^t^ <br /> i Owner - Y V\ A����i�� Address <br /> Firm Partners, Addresses and TU�IeoCh/ ecN bets <br /> L Business Telephone No. 1 0 > 1 Emergency Telephone No. <br /> I Contractor Licence No. C , <br /> Applicants Name (Print)LF-C. KaIl. 7-JAl� ..pate - <br /> Please check Applicable Category (1-7)-and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) o , <br /> For July 1, June 30, 19 Disposal Sites (- <br /> Description(Make/Yr.,Color) 1 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity - Gal.,Weights &Measures No. <br /> Equipment Parking Address - - - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Q <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. �1 <br /> Test.Location Test Date/Time <br /> 0. ❑ SANITATIONPER T 1 <br /> Job Addres /Locati, n J `h 1.1. I C �� �� 1 -t �'1 �jn, - /®�d0 <br /> Oyyywner Q 1"�T ` ( r .1 LV_ A <br /> p�SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑-PACKAGE PLANT - `Q <br /> /❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑'OTHER' <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 i <br /> Type Construction - - --- Disposal Site. _ <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. 0 PACKAGE TREATMENT PLANT For July T,-June 30,-19 - <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t em, w ro ^ens Hapn,Y �� tnnscen%s1 sthe'dfowfng "I certify ihei in the performance of the work for which this permit isissued,I shall notemploy anyperson rpy' <br /> I ^F 'fL C tiln:f( Wnrr_ a�q .l 1 uf;ez the fo owinF'fl3 '. 1 <br /> Lori rre ron P r I r cont. 1 , gRaL rararxs the foliewin8. I certify chhl in U;e p¢rfnrmin.,c of tire wark for which this permit is issued,I shall <br /> e T,.-.., <br /> I hereby certity t I have prepared t 's application and that the work will be done in accordance With San Joaquin County <br /> ordinances,state laws, d rules ifind reg I of the San Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY. <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July/ SAeceived By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE a <br /> LESS <br /> PRORATION r' <br /> PLUS <br /> PENALTY v �./ <br /> OTHER 2 y <br /> OTHER <br /> Received by Date 1 Receipt No. Permit No Is ante Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HA3ELTON AVE.,P.O.Box 3009 STOCKTON,CA 95201 <br />