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Applications will ue rrocessea wnen ouommeo rropeny ii omp,e,eu.or au,v ,u a,yrn ,ne
<br /> APPLICATION
<br /> (For Non-Transferable,Revocabler'and Suspel e) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> WASTE'-
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<br /> Application is hereby made to carry on business in th jurtsdictional area of the San Joaquin Local Health District _
<br /> N r . .mass�4a(DBA) L�15ri�luKF 5 PRoPf�lZ� 6dd�esslo3H8 '_ST,
<br /> i ar_ f LI/5lhNlClrs S Address.Ir,. .s�tfE :,.� ,. _.. 4� r , u•:� .... .; .- ..
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<br /> J Firm Partners, Addresses and Telephone Numbers V _.
<br /> n Business Telephone No. Zo91—9'/& —l.3 VS: _Emergency Telephone No.
<br /> < . ... ,._.. .1_ r.r t—L— c. -'lY G J _min, ,t.:. ..r-. ...I.,r..r ,1:J1. i+_: -,�
<br /> j Contractor Licence yr �I L. y raS 7G1• ccs.11U:aa —
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<br /> L Applicants Name (Print) L�/r1f� "'- 1.•t•_ :� :,"6�OL�lST .' u1L ir��_/3�9
<br /> Title Date,. _ --
<br /> >(!'.:7•_+ , .�,,r.n � IL J •7t r� r ,b: y. 3.,irt4: •1 H7,. [.I'C.-
<br /> Please
<br /> Cr-Please check Applicable CategoryInformation
<br /> (1-7)and Fill In-the Required
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -
<br /> For July 1, - -- June 30, 19 - ----- -Disposal Sites —--- - -- ---
<br /> Description(Make/Yr., Color)
<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 July 1, June 30, 19 -
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> �,{ ----
<br /> 3. JW PERCOLATION TEST !� _..- _ --.•- - _--
<br /> R.S. or R.C.E.Name I��hJl /NDN R.S. or R.C.E.No. ` Z-9 7- _
<br /> Test Location 1 $ ~S1 nth` /�✓ - Test Date/Time
<br /> 4. ❑ SANITATION PERMIT
<br /> Job Address/Location C --- --
<br /> Owner --' Address _ -
<br /> ❑ SEPTIC TANK --❑ CESSPOOL -• -'•-❑ LEACHING FIELD ❑ SEEPAGE PIT - ❑ PACKAGE PLANT
<br /> ❑ PERMANENT ❑ TEMPORARY ❑_NEW ❑ REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> + Construction --L.-= - Disposal Site -
<br /> [Units Equipment Storage/Cleaning Location(s) _
<br /> S ❑. ACKAGE TREATMENT PLANT For July 1,-June 30, 19 i i
<br /> Operator Name "t "' Where Certifled
<br /> Plant Location -
<br /> }PlantCapacity 1 _ N0. itsSlerved
<br /> r;
<br /> ❑ LAUNDRY Fo1July 1,-June 30,19 ( ' i I J— - 1i
<br /> 'SIZE: I❑ Less Than 1,000 Sq.Ft ❑ More Than 1,000 S�.iFt
<br /> ❑ DRY CLEANING Chemicals Used/Amount/Mo
<br /> (l l :-, y _f �'`<�tt ,sj . I{r.l` - ,tis1``' I '�"� lcloc�rhkAtli�per htsissued.lsbagnatp p19xvyrarson
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<br /> (Nom Q
<br /> In soar mallrier as m tteeontr+ to�rottaalYs ewe of C oMa. _#- . ) I n•(�t* t° f ) ) � r-
<br /> Cootra,Irse�s a s�i eonr+acW,Y,ai4r,M,r,e{�erl{lie+- +- f►[fiat
<br /> In .perlp!]llif!aE_at 1ne:work for trhfI ihLS permit is issued.I shall
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<br /> . growOl�settslif1a11tSlittaa �. r, �, t :�,. :. �.
<br /> t;.,.: t *',_� �.1:,..'t ti 3rd a '- - •�
<br /> 1 t�ereb�/"Certlfy'1fiSt �iat#�' tpared th�s'ap�lfeafro rt'and at he�nlorkjlvllf'be done in accordance Ith San Joagwn Coun
<br /> f 1 f,. . i 1 -.._ r ..r u
<br /> ;ordinances;stat laws and' s and regulatlo SarJoaquin Local Health Distract.
<br /> A, APPLICANT' SIGNATRE X
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<br /> R.DEPA ENT USE_ONL
<br /> DU@: ❑ A UA LY, ifY PER,UNI ,:, PER SIT :`.. i❑ EAC ❑,January t_3 Received By Jenuary 31,.'?9❑ Ju 1 3;RecerveA B'July 3)
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