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Applicat!onlmwlll 3e processed When S:15mlited Properly Completed.Se'c`ure To Sigr. The Apllcation. i <br /> AcPPUCA ti ION <br /> (`or Non Tran.:fernble,Revocable,and Suapendable) - -- <br /> a_iY"u'IR0NN1EI)TAL HEALTH ?ER o,IT <br /> L9d�?36D c'dRST[ <br /> ApOlicatl�ori �,h er7py madd�to c ion bu,ness in t ejurisdictional area of the San Jo'qu n Local yHealth�Dis/trictt <br /> r s= Name (DBA) c i- .--�✓�F!'C-% i -- _--Address: '' (ca _ .l L/ly /�" <br /> Address <br /> Partners,A,;dresses and'elephone Numbers <br /> >iness Telephone No. _�' - e% �L17J __---__- _- _ Emeroency Teleohcne <br /> ^ntractor Licence No. <br /> F'cants Name(Print)- - _ _-- -- Title Date <br /> e%n,e check App!ieabto Catebory 1 7)rind Flit in th6 Required Information <br /> 7. PUMPER VEHICLE PERMIT REGIS Tf2ATION(FOR EACH VEHICLE) <br /> ' F % 1.--- -June 30. 19 --- -- Disposal Sites - -- -- - --- —� s <br /> 7, _t;on(Make/Yr.,Color) -_--- _ <br /> iso. ---------- - ---CAL.Licenso vn. - - - - C.v ^nse Renevaal No.- ---- — <br /> city <br /> Ga:.,Weights R Mea <br /> .:.!Jlpment Parking Address -.--- <br /> PUM.PER YARD <br /> For July 1._-- June 30, 19 <br /> No. rf Vehicles Stored --- <br /> 1_ <br /> y P:' _'Chemical Toilets Stored-- --- ------ .______ --- - —_- -- _-_ ._ --- <br /> '.. PERCOLATION TEST E` <br /> -r9 <br /> C.E.Name R.S.or R.C.E.No. <br /> Location -- - — —---- - — Test Dale/Time ---- - --- --- I <br /> SANITATION PERMIT <br /> Addres /Location �Q C �_ ��1' -�• � X _ <br /> C an.er f T �_-�_ll <C --�t p S <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> r'--MANENT ❑ TEMPORAR" EW ❑ REPAIR ❑ OTHER <br /> S. CHEPI!CAL TOILETS Fol July 1,-June 3C, 19 <br /> OnstrUcticn_- Disposal Site_ W <br /> Units Equipment Storage/C!eaning Locations) <br /> YJ <br /> PACKAGE TREATMENT PLANT For July 1,-June 30, 19 _ d <br /> C tor! ame ---- ------ --- - -- -- -- ----- Where Certified ------ S ;'. <br /> t Location --- -- ---- - ---- -- <br /> nt C?oacity No. Units Served <br /> .`.L3f>S0PY For July 1,-,June 30, 19----- - - --- - - <br /> SC ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,600 Sq. Ft. <br /> CLEANING,Chemiaas Used/Amount/Mo. <br /> e- <br /> c <br /> 1 ,,,•, I ,, to nr n .;� t J :'>, f 1 , <br /> L'A C:•f h I Ix] PJr ,iJh C^^tTC I R l.•t t : 0.,:x.11. :.::'I J.` '.I ii'.ihf i.. ;.:?'.'. .... ..i . � a h.:l, <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances,state laws,and ru Bs and regulations of the San Joaquin Local Heaith District. <br /> AP.7_ ANT'S SIGNATURE X <br /> V <br /> - FOR DEPARTMENT USE ONLY _ <br /> Fen Is Due: 12 ANNUALLY C1 P;R UNIT 01 PER SITE ❑ EACH El January 1 8 Neceivetl 9y January 31 ❑ July 1 d Received By July 37 <br /> REMIT sad <br /> _ I�LING REMITTANCE $ <br /> EASE EXPLANATION CHECKED <br /> DATE I DATE REMITTED AMOUNT <br /> j <br /> m: L —_—_ - —_— — <br /> r - <br /> RAT.ON ; • j <br /> I <br /> 'E <br /> " '- NAL TY I <br /> OTHER <br /> C THEP , . <br /> -c.red by DAtr. F.—pt I lo. Purr t No Issua ne,e bate Marled Delivered <br /> .,IPLICAN r—kE'.'It,ALL COPIES TO: FN•".A7 V AEN'AL HEALTH PERMIT/SERVICES 1601 E.NA2ELTON AVE.,P.O.iHox 2009 STOCKTON.CA 95201 <br />