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' ApplicallOnf Will Of P,OC.ee.d wren bubr oiled P,noerly ComrWod B• '.:. r. To S gn Th. AAV"A' ' <br /> APPLICATION y <br /> (For Non-TrandarebM.11wOe8b4.ane Srlapendab%) <br /> ENVIRONMl►c''►L F'EALTH PERMIT I <br /> AnpllCttion rt hwr•hy made 10 carry on bul,ness in the IuTHdiCleonal area Of the`,.++��n � <br /> Urn L ah'Ct <br /> fi�'t�` n Srrb <br /> AddYx'y�% Nf <br /> M Rus,npsE Name :OR 41 S[=f /C r� CO <br /> Owner <br /> rE �/`t/�t AddrMt <br /> . - — - -- <br /> u Firm Partners. Addresses and/?O"phone Number} <br /> Business Telephone No yI -��[/ t� Emlrgenty Telephone N0 .. - - <br /> J Con•.actor Lictnce N0 17�r7 -- «» ! �r <br /> t ACplicants Name IPrint) L L^ <br /> P,~tAeek Applicable Category(1-7)and Fill M the Requtred Into►maBO" <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For.+uly 1. June 30- 19 D'sposal 94tes <br /> Description(Make'Y, Color) CAL L__.so Re^ewal No -- <br /> Serial No CAL License^Jo <br /> Capacity Gal.Weiohts&Measurer No <br /> Equ,pment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1._- - __. June 30. 19 <br /> No of YehjClea Stored <br /> No o1 Chemical Toilets Stved _ <br /> 3. 0 PERCOLATION TEST <br /> RS Or R C E No <br /> R.S or R C.E.Marne T <br /> Test Location Test late Time <br /> v� <br /> a. R.SANITATION PENM T <br /> Job Address/Loca <br /> /pt��ion /f��..�_6y /I� N <br /> Owner a a-- /1/I cAir� -- - - -- .- Addres3 <br /> ❑ SEPTIC TANK C3 CESSPOOL ® LEACHING FIELD 13SEEPAGr_=IT V PACKAGE PLANT Z <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAI'1 ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1. June 30, 19 <br /> Type Construction Lisposal Site <br /> No o1 Units Equipment Storage'Clean'ng LOCabOr1(s) <br /> 6. ❑ PACKAGE TAEATMENT PLANT For July 1, June 30, 19 Where C4WO ed <br /> Operator Name <br /> Plant Location <br /> No Units Served <br /> Piant Capacity <br /> 7. ❑ LAUNDRY For July 1. -June 30, 19 <br /> SIZE ❑ Lees Than 1.000 Sq Ft. ❑ More Than 1.000 Sq Ft <br /> ❑ DRY CLEANING,Chemrcnis Used/AmountrMo <br /> I hereby certify that I have prepared this application and that the work vi.-Il be done in accordance with San Jc,aqu,n Cocnty <br /> ordman es, state laws. an ales nrLd regutiiio s D1 the San Joaquin LOV-4 Heal.h District <br /> APPLICANT S SIGNATURE X �(. 7_ <br /> FOR DEPARTMENT USE ONLY <br /> ❑ JA^.ua.y i!AK!"Mt1 BY J. "'r�� ❑ July r a FNr�•+'"1 ev J,r'r <br /> Fee Is Due: ❑ ANNUALLY C3 PER 11NIT C3 PEP SITE ❑ FA(l' REMit <br /> BASE EXPLANATION BILI INC REMITTANCE 1 I AM7l1NT D1if CHECKED <br /> DATE DATE QEMiTT10 AMOUNT <br /> FFE 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PF NAL TY ' <br /> OTHER <br /> orHER <br /> :4,4 LA 7. �d� �3r-I <br /> .[ef[ NA2[LTON Avg..O M!e0[ ITOCATON CA e1M- - <br /> APPLICANT-e[TVQN All COM[!TO [Nv1110NM[NTA �e4171T4 •' Inc �(�/,�f t,, 12- <br /> 1 <br /> /_ 7 G <br />