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Applications Will Be Processed When Submitted Properly Completed. Be Sure To,Sign The Application. <br /> APPLICATION <br /> f (For Non-Transferable, Revocable, and Suspendable) <br /> _•Z4" ENVIRONMENTAL HEALTH PERMIT $EpTgGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the-jurisdictional area of the San Joaquin Local Health District <br /> Business Na a (DBA) Address <br /> a Owner,_ e, Address T� .5-is-9 <br /> Firm Partners, Addresses and Telephone Numbers l6 5z-/ gefi SpLr`V rJS ��/Z, <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) il t,- Title, y _ Date Z'.3 <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> _,�• <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 /> t Capacity' Gal„ Weights & Measures No.- <br /> Equipment <br /> o: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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. Cff SANITATION PERMIT '— <br /> Job Address/Location if <br /> Owner fa i✓1_f Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ,L❑ NEW rL ❑ REPAIR OTHER ljccr•d�n <br /> 5. E] CHEMICAL TOILETS For July 1, -June 30, 19 C <br /> 'Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT .For July 1, -June 30, 19 <br /> Operator Name r Where Certified <br /> Plant Location .. I <br /> -r�.. t 1 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. Y <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.Nam ! <br /> s <br /> in ow rarric nseemesub tFSr:etts." It=�Cn�heet+'l�Y�np'"hartfyth�•inthcnerfsrmaycectibevrerkfor tvhictt.his permitisissueJ.lshalfnot empfayany petson =� <br /> Contractor's Wring or sub-Gentrar::'rq) s.t4n3tute ;.P t, s i o` e;;�ti�;ng: "i certify tha'in the pertormance of:So worl,for which this pormit is issued,I shall ' <br /> employ persons subject to we.Fkoan s cwnpensaiiol Ws 1 C h'i; <br />