Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sun To Sign The Application. <br /> APPLICATION <br /> 'or Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT �EPrA'E <br /> LIQUID WASTE _ <br /> r Appl caloon is reby made o carry on business in the jur dictional area of the San oaqu Local Health Distric.. <br /> q Business Name(D A) -s,�a {' o._. - <br /> �.c � �-t�^r�'=1��. r�'%Ft.�_ Address <br /> iOwner__ :.}xjp-.e� �+�/r Address <br /> CL Firm Partners, Addresses and Telephone Numbe --- ----C; <br /> CL Business Telephone No. _-�C F_{/ S - - Emergency Telephone No.-__--__�— <br /> I Contractor Licence No.—_ 3 2 <br /> �Applicants Name(P•mt)_ �sl��__ _.__ Title —�� -�__Date--- <br /> Please check Applicable Category(1-7)and Fill In the Required Information �J <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) c <br /> For July 1,---- June 30. 19 Disposal Sites _.___._ _-- --- -- <br /> Description(Make/Yr..Color) ---- —- <br /> Senal No —___-----_-- —CAL.License No. .._-__--- __ CAL,LIR Renewal NA-._.--___.- <br /> Capacity _ Gal.,Weights&Measures No. -- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored --- <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name ------ -- --- --- -- R.S.or R.C.E No. - -- - - <br /> Test Location ___ —_--- - _.___ .--._-- -- Test Date/Tlme.— __ <br /> 4. ❑ SANITATION PERMIT_ P ` <br /> Job Address/L on___ yC `' _. _ A►J! I.I�t� -s2��- --- <br /> Owner _��_ /2l-I �•Lc, _ AddrMs� O _ �^!� �I •e AA_ _ - -- -- - <br /> ❑ Sit 11C TANK ❑ CESSPO� LEACHING FIELD LEPAGE PIT 0 PACKAGE PlAN1 <br /> CIPERMANENT ❑ TEMPORARY ❑ NEW LA REPAIR ❑ OTHER r. <br /> S. O CHEMICAL TOILETS For July 1,-June 30, 19 I Q <br /> -ype C7netfuCtion -- OlspOsal SRO <br /> No cf Un,-4 ___ Equipment Storage/Cleaning LOCAIWIS►.-- _. .J..__ __r _. .. - s• <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1.•June 30, 19 -- <br /> 0 perator <br /> .-._-.__.Operator Name Where Veftltltd <br /> Plant Location `-- - <br /> Plant Capacity- - _._.-!�_ -". M _ _ No,U"ft QN11W <br /> 7. ❑ LAUNDRY For July 1,-Jun,30, 19..-._.. <br /> SIZE ❑ Lost Than 1,000 Sq.FI., ❑ More Then 1,000 Sq Ft <br /> ❑ DRY CLEANING,Chemicals Used/AmounttMo -_ <br /> I hereby corlify that 1 have prepared this application And that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules W regulations of 11114 SararrlJoaquir Local Health DIsirtCL <br /> APPLICANT'S SIGNATURE X <br /> FOIL oE►ARTM["T U"ONLY o <br /> proll,IS 000: Alill#UALLY ❑Prot trot O Far.tin ❑FACH _ O j&%Wr ar knw $1 O my t s A.e«..e nr-tv,r <br /> alt LWa I WWI 1 <br /> east rl1PLA►MtIDN parr i DA otcurrreD AST bl's cMtcotro <br /> •rsL► <br /> wwo,Arra+ -- <br /> �riFit - - - --_- - -- _ _--- <br /> Dr-*" <br /> i'. ...e or ale wi ii D�CIRT0 <br /> _.--- y�.Cur-wenlwr+AU coma 10 glinnooNsawTAL WALTN PIMPT/WMV 4 /r 1M<KAnLT Va,/o.aM MM stOAtOu.CA attar <br /> r <br />