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<br /> Application%Will R^prry
<br /> r Y.'I••n 3"tirr trct : rear fly Compleletl He Sure To SI n The A i'
<br /> 9 PPII,�RNrn
<br /> APPLICATION Y'
<br /> (F, , •lnn•Tf,r.;Irrabin. Revocable,and SuspennAhl,•1 tf
<br /> rrIVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE f'
<br /> Y hi'• r• • ;,n th, jurisdictional a/RA OF th,• y� ' "x
<br /> Business Name(DEiAi C•"ApPilralion�de��{/�'4c � - t . ' ,i I�r�alu,C. 1
<br /> z Owner IIQE'.d�C ( 6 S�sti��-3��✓.nrtiress .Z�3 S, X71 �►'' �,��
<br /> Address 1,T (=";7 SI
<br /> Firm Partners,Addresses and Tel.phone N„mth,.•
<br /> Business Telephone Nc. ��-,3�4 •�
<br /> Contractor Llconce No. Emergency inlr.phur,.,No
<br /> /, +'a
<br /> Applicants Name Pring Title r--14'7A, +"�y�.,v �? T
<br /> Please check Applicable Category(1-7)and Fill In Ir:-Required Inlr•mation ' Date —
<br /> ,ICE
<br /> 1• 13PUMPER VEHICLE PERMIT REGISTRATIny (F OR EACH VEHICLE)
<br /> For July 1, June 30, 19 D,spos.11 Sites
<br /> Description(Make/Yr..Color) ..
<br /> Serial NO __ ^41 L,crvr^e"lo
<br /> Capacity CAL.L, _-se Renewal No
<br /> -- -.-_--- _. Gal..W ti;ht;R Measure;No _ _
<br /> Equipment Parking Address . I
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19
<br /> No.of Vehicles Stored
<br /> No. of Chemical Toilets Stored DIP
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S.or R.C.E.Name W
<br /> -- - H.S.or R.C.E. No.
<br /> Test Location ''�sl Date,Time
<br /> 4, X SANITATION PERMIT -
<br /> Job Address/L ti �e / 01
<br /> OwnerAddress
<br /> SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD J�r SEEPAGE PIT ❑ PACKAGE PLANT 1
<br /> PERMANENT ❑ TEMPORARY X NEW ❑ REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Type Construction
<br /> ----------_--- Disposal Site
<br /> - -No.of Units _—_ --- -
<br /> Equipment Storage!Cleaning Location(s) - -
<br /> 6. ❑ PACKAGE TREATMENT PLANT F: JUI 1. •June d0. 19 I
<br /> -
<br /> Operator Name --- -. - -
<br /> - y Where Certified
<br /> Plant Location --- - - ---
<br />'P ant CapacityNo. Units Served
<br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 °gam - --
<br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ Moro Than 1.000 5q. Pt. `r z
<br /> DRY CLEANING,Chemicals Used/Amount/Mai y
<br /> ti
<br /> I hereby certify that I have prepared this apphcntlun and that the work will be done ,n accordance with San Jonnuln County 1.
<br /> ordinances,State laws,and s a d rorlulntion:•of the San Joaquin ocal 1'iealth Dlstr�1. eve
<br />,NPLICANT'S SIGNATURE X k '
<br /> t' '15
<br /> X1:77.
<br /> I'OR DEPARTMENT USE ONLY 1
<br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT ❑ r•1 n-ITT ❑ EAC11
<br /> _ D January t 3 Recen, , ''32 D July r n it,
<br /> •IARF !YI'I ANA f 11 I fill I nF'MITTANCC
<br /> 11A IAMOUNT DUE
<br /> DATE
<br /> IN
<br /> i I nrtiU
<br /> FEE r IIr•�-e�• AI: '
<br /> LESS (%��`
<br /> PRORATION
<br /> � 1
<br /> PLUS
<br /> PENALTY .C1T�
<br /> OTHER )e, _. ..
<br /> OTHER
<br /> necc,ved by Ua'• Ib•,.,q.t Nn Pe—.1 No -
<br /> ... Ifauanca Uate 11telleQ Dahv,•m,i
<br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONNI N1 A' Ilf AI T11 PFn11IT IS rRVICES •!•1!p HATr9.rrw.,r P(1 !.p,}• ^ •• •I - ..
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