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Applications Will Be Pro._ssed When Submitted Properly Completed. Be SwK To Sign The Application. <br /> APPLICATION t�� <br /> (For Non-Transferable, Revocable, and Suspendable) 5-gz- 186 <br /> ENVIRONMENTAL HEALTH PERMIT 2�AFZCEI�. <br /> LIQUID WASTE <br /> Application is hereby made to tarry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r <br /> a Business Name (DBA) _-_—.-- <br /> 4 Owner _ TAMES _�(�Q1nrEtJS _ Address .7719 F:A= I. SQAQ�A�'Af C.d.QS220 <br /> Y Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No _ ._ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) _�,I�F R_ 1c . CU �. LS__ __ Title<'%'v 11- I"Er-R - Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information C E 1ISAM' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 44.18 MA7T;4EV, PLAZA <br /> ��_ <br /> For July 1, June 30. 19 Disposal Sites �,,o�1CA. 95240 <br /> ��� <br /> Description(Make/Yr, Color) _ CSA)3GS 415 <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 Jul 1, _ June 30, 19 _ <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored. <br /> I ES NAA 4-EW I <br /> 3 13 PERCOLATION TEST C 209 X09-41 5 9 / <br /> R C.E. Name Wp,L'TFJZ,'_E, I jR.C.E. No. I1nP-4- <br /> TeS' Location 77L9_I_AZ'T P'E1_?IERR!!:�Atl Test Date/Time__Ptft_nnAi_19Z,WEnkiEs��y <br /> 4. ❑ SANITATION PERMITACAI�tPOICA, ff522p P�Rl7�rTnatd REf1L1iNG L`.�Q- 3�ryJ}?N(. <br /> Job Address/Location (SEE 1Zrmx eRm a_mLn.IEr_;-may-L nc inbA uA� __ <br /> Owner ------- Address. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT res <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER _ <br /> s. ❑ CHEMICAL TOILETS For July 1, -June 30, 19U L 2_ <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 __ _ _ Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served _ <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws <br /> 4/. c.F.# i t584-- <br /> APPLICANT'S SIGNATURE X ._L41 J �/� .C�' Title CIV LL Etc_ Er- Date II -3n` 9 <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ­0 January1 A Received By January 31 ❑July 1 &Received By July� <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE EXPLANATION DATE DATE REMITTED AMO DUE CHECKED <br /> AMOUNT <br /> FEES --- <br /> LESS <br /> PRORATION <br /> PLUS — - -- --- --- --- ------- --�- --- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec Date Receipt No Permit No Issuance Date Mailed Delivered <br />