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r Application'.W01 f3.• Proc,,s"d When Submitted Prupetly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> 1For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERN;.T 5[I'TAGE <br /> LIQUID WASTE <br /> APu�icat: .,hnn'h1 •••.r!••to r n ry on bushes¢In the jurisdictional area of the San-Aoaquin,Local Health District � <br /> Namj.(ID EtA '___ �-: /l! _ .f(.'_�C" <i f'C�Address. --- <br /> �" _S. . <br /> Address � --- - ---- - - -----rye <br /> .•n;..5. Qddr,+c.ea.i.,.t -c.l.,;'u,,.,. Numhl+rs <br /> Telephenp No _-'C ` Emergency Telephone No. <br /> .. for Licence NO "'..' - S _ •� - --- ---- - - --... <br /> tz NarnP fPnntl _ { {,- Title Date <br /> check Appl!cable Cateqory (1-7)and Fill in the RequiredZormation J <br /> CJ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L'I <br /> Junp,i0 19 Disposal Sites -- - - — - -- — ------— <br /> (Make/Yr..Color) <br /> r "do CAL.License No. CAL.Liccrse P.crcw•at No. <br /> !V Gal..Weights& Measures No. - --- -- - ------- — <br /> I.., ...ont Parking Address <br /> ❑ PUMPER YARD _ ~ <br /> c .r ,flay 1.. June 30 19 <br /> No nl Vehicles Stored ---_-.__-- __-- ---- — 1 <br /> N•- of Chemical Toilets Stored <br /> 3. O PERCOLATION TEST <br /> R S of R.C.E. Name R.S.Or R.C.E.NO. <br /> T^9.t LocationTest Dal e'Timd'..r._ <br /> 0. C3 SANITATION PERMIT - + <br /> Job Address,LOca 1 n 7i ''."�/ c �' . �� = • _!� - --------- —-------- <br /> Owner •,.. -� 1- _I" << Address _ a/ --. c_. -------- ---- — <br /> r' -PTIC TAN C3CESSPOOL C3 LEACHING FIELD 13 SEEPAGE PIT '❑ PACKAGE PLANT r <br /> 11PERMANE 1:1TEn01PORAR+' ❑ NEW EI REPAIR ❑ OTHER ItA <br /> 5. ❑ CHEMICAL TOILETS c July 1 -June 30. 19 <br /> Tyor'Construction Disposal Site <br /> No of !snits Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT F:)r July 1. June 30, 19 O <br /> Name <br /> Where Certified <br /> ,c anon <br /> PlantCanaclty No Uni!sServed _- ------- _------ ._-- _. <br /> 7. ❑ LAUNDRY For July 1.-June'30 19 <br /> ❑ Less Than 1.000 Sq Ft ❑ More Than 1.000 Sq Ft <br /> ❑ DRY CLEANING.Chemicals Used:'Anionnt Mo — <br /> I hereby certify that I ha.- •^'I this :lnpticaQUn and that tho Work will be done. In accordance with San Joaquin ounty <br /> rrdcnance statn haw, uvt rnqulations of the San Joaquin Local Health District <br /> r.c n ,7ANT'S SIGNATURE X <br /> }p. FOR DEPARTMENT USE ONLY , <br /> Fee Is Due: [I •�•.•:� •, C1i' r) iii n'A it ❑ 1 Arai ❑ jAn,ir;X f 6 R►cen.d Dy innt,xy 11 ❑ .lury i A RPrei„ I Py July n <br /> REMIT <br /> Iul1 Wt; REM11 TA tF. 3 .;NECKED <br /> i.l t .i..n•,nnnr, AMO1!'.•`T DUE", <br /> 1)AIF 04fE i RfAItTTED AMOUNT <br /> ..I 1. <br /> i�ruilmo oil. A1yii.it71ZT0CkTAPPIK ANT of TWIN Atl , T• INva- 4M/N1A1 HrAI T//PfAMiT 111V,C1 lea$a NAll'tTON Avg.P O seratIOM lltI <br /> a$ a . J- w. i - "..x, 1Y1... I v,a-..vd"-0,N n.x- A, .'20, <br />