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..PPllcations Will Se PrOCNaed when Subm"I LICATIONpleted. Be Sure To Sryn The Application. <br /> APP <br /> (For Non-Transferable.Revocable,and Suspendable) ` <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereoy made to carry u�1 business in the jurisdictional area of the Say Worn Local al�District <br /> Business Nan a (DBA) <br /> •L. r Ct ,_'� Address / , r• t� `� , A <br /> 1. �✓1(.C� Addresr <br /> Co tinpr wl, <br /> 12 Fit,- Partners Addresses ani) Telephone rNu�mbLers "V <br /> 7 //� J Emergency Telxphone No <br /> kBusiness Telephone No S r �. � <br /> Contractor Licence No 7/ 0 O <br /> < �. 4/'�� •�J�' T Ce ex, raves Date y <br /> Applicants Name IPrinl) <br /> pi""check AppMcabN Category(1-7)and Fill In the Required Inlormatldn <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July t J-1ne 3U. 19 Disposal h'i's <br /> Description(Make.Yr.Color) CAL CA: <br /> Sepal No License <br /> Capacity Gal Weights &Measures No <br /> Equipment Parking Address <br /> Z. ❑ PUMPER YARD <br /> For July 1 June 30 19 _ <br /> No of Vehicles Stored _ <br /> No Of Chemical Toilets$10100 <br /> 3. ❑ PERCOLATION TEST RS or R C E No - -- <br /> R S or R.0 E Name _ <br /> Tort Dale Time <br /> Test allot) <br /> a. 4a SANITATION PERMIT 7 y Q c <br /> Jcb Address Location I L� <br /> OGCC Address <br /> ��% ��z <br /> SEPTIC TANK ❑ CES,SPOOL W LEACHING FIELD ❑ SEEPAGE Pit 13 PACKAGE PLAN f❑ PA HFH <br /> 13 PERMANENT 13 <br /> TEMPORARY ❑ NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For Ju+y 1.- June 30 19 <br /> Type Construction Dl%pusal Silo <br /> No of Unit'. Equipment Sluraqu Cleaning Lucati0n(s) / <br /> 6. ❑ PACKAGE TREATMENT PLANT Fur July 1 - Juno 30. 19 Where Certified rMU�1 <br /> Operator Name <br /> Plant Lucm,un <br /> No Units Surged <br /> Plant Capacity r <br /> 7. ❑ LAUNDRY For July 1.•Juno 90. 1g <br /> SIZE ❑ Lost, Ih,ul 1 bW Sq F1 ❑ More Than 1 UW Sq Ft <br /> ❑ DRY CLEANING Chemicals Used•Arnount Mo <br /> r1 <br /> I hereby Certrty that I h l%u prepared th,b application and that the work will be dnne in accurdance With San Joaquin County <br /> oWinanCub blat%'Idwb and/rules an <br /> ions Of the San JOaqu,n Local HuXin Diblr,Cl <br /> APPLICANT S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNi,AIIV O PEN UNIT D Pur SITE ❑EACH ❑ January t a R,e,,nraq Ny)anuair ❑ 1 r y i a Nri.i•i.,n) J,.iy <br /> PEMIT <br /> t!A•,E lkVIANATION <br /> (lit IING 14EMITYANCE 1 AMOUNT Out CHECKED <br /> DATE DATE Rt M11 TED AMOUNT I <br /> PAORAT iON <br /> Pt U] <br /> PF NA,T V - <br /> G1..EN <br /> r 'HEM <br /> ) <br /> IG <br /> n, u.r.• <br /> i,..�..,1 i�.:, Prim.l Nu ..�,,•,.. ;alp Mailed D.�..,...t <br /> -- _. <br /> APPLICANT-RETURN All COPIES•O ENVIRONMENTAL HEALTH PERMIT SERVICES <br /> 1601 E NAZELTON%VE PO Bo.7009 LTOCKTJN C♦9520 <br />