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r�' �t <br /> i (may] � <br /> . '' ',• <br /> 4 i �•. r t I ty „ <br /> Applicallons will Be Processed When Submitted Properly Completed Be Sure To'Sign The"Applkatlrn fit r> <br /> p " `APPLICATION `. <br /> {, � , <br /> (For Non-Trhnslerable Retiocabie and Swpendabla) EPTAGE y <br /> E13V1RONMENTAL HEALTH PERMIT S ` <br /> #: Applrcetr Is heb adetolar a business In 1h unsdfrlfona{area of iT n J quintocet eaftrh DI tnCt <br /> E '!I? a ff.�?Y.✓J .SLjtiC Address �!/JC-:��� j:.1.L *!j : <br /> y Business Name(DBA)_ 1 / � .� a <br /> %�Owner Address � ry <br /> Firm PartnersAddresses anti Tel ne' <br /> Emergency telephone No r ' <br /> $Business Telephone No,, _ � � <br /> Contractor Licence NO-- �� �/' ��--1j <br /> ` <br /> Applicants Name(Print 1`! 71tIr l Dale !sem , -- � <br /> Please check Applicable Category(1 T)on. Fill In the Required Information <br /> �A- <br /> 0 PUMPER VEHICLE PER1VIfIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1. June 30 19; Orspoaal Sites " v� Sw y, <br /> Descnptlon(Make/Yr Colar) - -- — <br /> s 1� <br /> CAL.Licens <br /> Serial Noe No CAL License Renewal No hd� • <br /> - rr <br /> Capauty GaI:.Welgyts&Measures No - — - <br /> `.4 c <br /> pts , <br /> Equipment Parking Address s � , <br /> Z ❑ PUMPER YARD; e rTK <br /> For.July 1, Juno 3b 19Hk <br /> a <br /> No.of Vehicles Stored' °u <br /> xM <br /> No.of Chemical toilets StoredOr- <br /> ❑ PERCOLATION TEST <br /> RS:or R.C.E'Nam6 R S or R.0 E No i <br /> Test DaielTlme n " <br /> tes' ovatiL on: k, <br /> 4. SANITATION PERMIT' r <br /> Owner r Address 1u..�-T - <br /> ❑'SEPTtC TANK ❑ CESSPOOL _ LEACHING.FIELD SEEPAGE PIT C3 PACKAGE PLANT <br /> ❑ PERMANENT—' 'E] TEMPORARY ❑ NEVV ;. REP,APR OTHER <br /> rrrre ,. <br /> 5 ❑ CHEMICAL TOILETS 'For Juiy 1, June 30 19 <br /> u Si <br /> �i:.Type Construction Disposal te <br /> + No,of Units `12Equipment Storage/Cleaning Location(s) <br /> 6-;.0 PACKAGE,TREATMENT PLANT�For'July t Junc 30 19 _ w <br /> _ <br /> _ here Certified <br /> -- <br /> Operator Name Y <br /> ( Plant Location <br /> Plant Capacity <br /> No Units Served..------ � - <br /> ` - <br /> 7,. ❑ LAUNDRY For July'l -June JO:14 <br /> SIZE: 11 'Less Than 1,000 Sq Ff , © More Than 1,000 Sq.Ft. , <br /> I © DRY CLEANING Chemicals Used/Amounl/Mo. <br /> vR <br /> I hereby certify that l have Vrepared this a plication and that the work will be done in accordance with San Joaquin County f <br /> ord+nances,'state Iaws;.and r es and r ul tions- f l e San in Local Health District. ; y= <br /> APPLICANTS SIGNATURE X — - -— -- - <br /> :� <br /> s <br /> FOR DEPARTMENT USE ONLY 4 <br /> - Fee l9 Due. ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH -- 0 Jonuary�6 Pctewed By January 3$' ©July I d-Recenetl El Juty <br /> - I - REMIT _ a . <br /> BILLING REMITTANCE S - -AMOUNT DUE CHEC%ED <br /> BASE7' EXPLANATION ,! ! REMITTED s ' <br /> DATE� .� !!' TE AMOUN <br /> MLESS <br /> FEEr <br /> c <br /> w,4 PRORATION - i•'� F _ � _- .- - --- t <br /> PLUS <br /> i. PENALTY <br /> 4 4 <br /> OTHER - - J• 1��� ..�._.r _ -h.-.�.--- - t -'§ <br /> r <br /> I e---� p�lw Receipt Na Pe+n I1 No. ISSWrrC!Deie Mailed Delivered <br /> I[L-� APPLICAN7�pET11RN ALL COPIES TD: ENVIRONMENTAL MiEALTH PERMIT/SERVICES 16 1 E.kAZELTON AVE..P.O.Bas?C07 STQCI[TON,CA <br /> u� <br />