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Applications Will Be Processed When Submitted Properly Compieteo. be sure '0 0191; i tic myy,........,..
<br />APPLICATION
<br />(For Non-Transie:rable, Revocable, and -Siiipendable)
<br />
<br />ENVIRONMENTAL HEALTH PERMIT SE Pi-AGE
<br />11 LIQUID WASTE
<br />Application is heret ade to carry on b ,siness in the 'uri ictional area of thp,SatzJoitpuin Localpialik2 Distqgt. .
<br />1-i-
<br />.. • ZNI.— Address _et) ez)te t_q:lo
<br />Business Name (DEA) . ") > '
<br />z Owner • Address
<br />tt A
<br />L.:: Firm Partners, ACdresses and Telephone Numbers
<br />a. Business Telephone No. _ it Emergency Telephone No.
<br />a .
<br />2, Contractor Licence No. -a, I
<br />7-1."-• ...'"' '1. I Applicants Name (Print) 1
<br />Title • 1 7":V;-,t orY4Irtr Date --t,..11- 41$42..._
<br />Please check Applicable Category (1-7) and Fill In the RequiredrformatIon
<br />0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br />For July 1, June'30, 19 Disposal Sites
<br />Description (MakeJYr., Color) it. I Ki
<br />Serial No. 1F-- . CAL, License No. CAL. License Renewal No.
<br />.
<br />Capacity '' Gal., Weights & Measures No. __., --,--- _
<br />„........ r • -•'-- .A.."' i ..,"
<br />....:
<br />Equipment Parking Addres's-. .-
<br />0 PUMPER YARD
<br />---,77---
<br />,.• , • .. e ' '`I
<br />For July 1, June 30, 19 0 .1...41 '''4' ' ,
<br />No. of Vehicles Stored • - N.. - ir -•'...
<br />No. of Chemical Toilets Stored
<br />/ sioir.
<br />1 i 1 ., '
<br />3. 0 PERCOLATION TEST
<br />i 1
<br />, .
<br />'. FIS, or R.C.E. Name FIZ:-or,,R.C.E. No. ,..._
<br /> , Test Date/Tima''.. /le '1••••;',.. , 4/ '10
<br />Test Location 4 ,
<br />II
<br />,.......- h /
<br />4.000ANITATION PERMIT ... , ;,,, .
<br />Job Address/Location tit..1 Pr) II . ,.‘........4.
<br />Address 90110'irree - • se°
<br />..,e.r • —LA
<br />A Owner A,Meleta 4-kethi
<br />0 SEPTIC TANK 0 CESSPOOL i 5r,v.LEACHING FIELD X,SEEPAGE Pp/ 0 ,f;ACKAGE PLANT .44."'N. s' •
<br />RPERMANENT 0 TEMPORARY , 13 'NEW eirREPAIR /2„. OTHER 4 ( / k „p„....4..... - -. : f •
<br />0 CHEMICAL TOILETS For July 1, June 30, 19 '' ''' . :Ila . . -.' .L.F k
<br />...'•
<br />Type Construction , ! • ?. % Disposal Site / *• - ,/
<br />No. of Units Equipment Storage/Cleaning Location (5)1v 4. ,....
<br />0 'PACKAGE TREATMENT PLANT For July,f ,•- June 30.19.,.-46 '. ,41 .-- t Where Certified
<br />_ \ ,
<br />,"
<br />FOR DEPARTMENT USE ONLY
<br />January 1 & Flece;Yed By JanuarY 31 0 July 1 & Received•Ay July 31 •
<br />rev IA 1....M. 6-• P,1••••0.4,•.,
<br />{
<br />4 61 • •—•
<br />BASE
<br />,
<br />••••••• • ..• •
<br />I
<br />EXPLANATION
<br />—
<br />'..1 BILLING
<br />iDATE •
<br />REMITTANCE
<br />.....—......—..DAT,E....—..-......,....BEMLTZED
<br />$ AMOUNT DUE
<br />REMIT '
<br />CHEp.(ED
<br />AMOUNT ,-
<br />FEE 4 .......4";7". N.
<br />N.. _...,.._
<br />N
<br />LESS PRORATION •
<br />PLUS
<br />PENALTY
<br />;
<br />"‘ .
<br />OTHER
<br />1.
<br />OTHER
<br />. s.— —... ... • . .r. .I. ‘
<br />- .
<br />IN t r4 ,
<br />OE\ 51 ii ll 1 ../ ‘,
<br />Operator Name ,
<br />.F
<br />Plant Location ..,_
<br />
<br />Y i .NN- ' ".•'.
<br />-, /
<br />Plant Capacity - *NqI:Units.Served • ...
<br />7. 0 LAUNDRY For July 177-, June 30. i9_ c -,,. r, :Th
<br />
<br />: 1'
<br />.5' c.
<br />SIZE: 0 Less Than 1,000 `gq. Ft,, q More Therr-110004cp4F.t. . .4,
<br />0 DRY CLEANING, ChemicaUsed/Amotiratikilii:'-' i.....=V — / 4
<br />
<br />--. ---d- -
<br />
<br />; ! ,......0-* u ,
<br />
<br />-......i. I 0.1:\ ..:. ,•• _I-1 •••••,-__ •/ '
<br />,e's
<br />L. .4--... tz_li "al 4 •,. t ,./..
<br />
<br />1 ..--; "'N. - /
<br />I hereby certify tha .have preparedethis•apqoatyn and that the work will be done in accordance with San Joaquin County
<br />, ordinances, state law4,and rules and4agulatiori'M't1 Saili loaquin Local Health District
<br />APPLICANT'S SIGNATURE X .4..,4- ....r.:"..........,
<br />
<br />. ' 1,'••
<br />alre
<br />CIUN4Le. og
<br />
<br />7191'1 .1,74: - -.4 t •
<br />
<br />Receipt No. errnit flecetved by Date
<br /> APPLICANT—RETURN ALL COPIES TO;. ENVIRON/AENTAL HEALTH PERMIT/SERVICES _
<br />v
<br />Mailed I Delivered
<br />1801 E. HAZF-LTON AVE., P.O. Box 2009 STOCKTON, CA 85201
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