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' Application:Will Asstrd When Submitted P _ <br /> ropady Completed.BeBa Sure To>Ign The APPIkaPon. <br /> APPLICATION <br /> (For Non-Transferable,Rerocable,and Susperidable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> tp�g� �o• �UOUID WASTE <br /> Appll'allonos henlhy n�INCJgrr_ isr� - (unsdiclbnslarea of lfq paqur 1/�W [Nstf�� <br /> a Busmns DBA ✓Y:g�'\\//�� - Address.,, <br /> Owner._ —/ <br /> __ Address— <br /> Partners <br /> ddress— �(v// CoQ <br /> Firm Partners,Addres..es and Telephone Numbers—17v-r 12.36 <br /> — _.__—._ <br /> Business Telephone No.. — <br /> .�ipr�-%3j _ <br /> _.. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print)._�C,[.(',iC slFC�f Title _ G7µ- _Date ...GO/1s r- - <br /> Please Check Applicable Category(1-7)and Fill M the Req+Ared InflMmatlon <br /> 1. O PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> FDr July 1, June 30, t9 Dislymi Sitar <br /> Description(Make/Yr., <br /> Serial icy _ CAL License No, _._-_ CAL License Rising"No.__ <br /> Capacity __ Gat.,Weights d Measures No. _ <br /> Equipment Parking Address <br /> 2, 173 PUMPER YARD --- - - �- C, <br /> For July 1,__June 30.19 <br /> No,of Vehicles Stored <br /> No.of Chemical Toilets Stored --'-- <br /> 3. ❑ PERCOLATION TEST — <br /> RS.or R.C.E.Name _ _R.S.or R.C.E.No. <br /> Test Location __ . Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> 7 Job Address/ ovation <br /> Owr)er13' <br /> ��SEPTIC TANK 13 CESSPOOL LEACHING FIELD 21SEEPAGE PIT 13 PACKAGE PLANT <br /> L✓PERMANENT ❑ TEMPORARY ❑ NEW (ITREPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 <br /> S. <br /> Type Construction _ _ Disposal Site <br /> o.of Units Equipment Slorage.ICleaning Locatwn(sl <br /> i <br /> S. 13 PACKAGE TREATMENT PLANT For July +.-June 30. 19 <br /> Operator Name ... _ . _._ ..__. Where Certified 11 <br /> Plant LOCahOb <br /> Plant Capacity_,___ _ ..... <br /> __ - No Unnc Served <br /> 7, ❑ LAUNDRY For July i,-June 30 19 <br /> SIZE: ❑ Less Than 1,000 Sq.Ft.. O More Than 1,D00 Sq.Ft. I" <br /> 0 DRY CLEANING,Chemicals Used/AmounVMo. .__._.—_ <br /> 1 hereby Certify that I have pre reo this apptic rand at the work will"done in a_cordanca with San Joaquin County a <br /> ordinances,state laws.an es no,, utatio o Joaquin Local Health District <br /> APPLICANTS SIGNATURE - .... _ _ _ _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Out:❑ ANNUALLY ❑PEN UNIT ❑rut snr ❑ MOI ❑ Arwry+6 Rxas.w By Js-.ay 31 ❑Jwv t b ReCawW er JWY TA <br /> nil uNG nEMn TANf.E L REMIT ` `JJfS <br /> aASF. EAIn aVAi ION IJaIF IT TE REMIT ED ANOUNi WE CNECREU e <br /> • _ AMOLMT <br /> GEE <br /> LE�PRO <br /> RpNPllr" <br /> PLUS ,L\F <br /> OTHER <br /> ,I- <br /> MMM M.aw <br /> APPLICANT—RETURN ALL COPES TO [NV.-MMEWAL YIEMTN KRMIT SERIF Cr 5 IMIE.N CLTd1 Ar[.eQ ' SrOCKTOM y[al CA <br /> fY-Ga�}e�— <br />