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Applications Will 8e Processed When emitted Propsrly Completed. Be Sure To sign I ne Application. t
<br />APPLICATION
<br />(For Non -Transferable, Revocable, and Suspendabie) SP�AGI 1
<br />ENVIRONMENTAL HEALTH PERMIT
<br />LIQUID WASTE
<br />Application s hereby mane to car 4 on business in ,he jurisdictional area of the San Joaquin Locai Health District
<br />7 -
<br />Business Na r (DESA} �� r'd_....... _ Address t
<br />zOwner�� -..... ._._ Address
<br />0 Firm Partners. Addresses and Telephone Numbers.,_..
<br />_-..�..�—._..__
<br />t
<br />nom. Business `telephone No, ���-��.� �.____.._ .. __. Emergency Telephone No. __. .— ---- _�---.. I
<br />-d Contractor Licence No.
<br />� Applicants Name (Print} _ —. �?.._L � _ R=�j _ � _ Title _ ' _..—_ Date ._.. .
<br />f i ti
<br />Pieria check Applicable Category (t -7j and Pili rn the Required n orma nn
<br />...,, , ,..,.
<br />1: 0 PUM, PER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br />-. ...............
<br />— � ___..
<br />BILLING REMITTANCE �
<br />For July 1, _ ---,.,June 30, 19 _.......... ..... _ Disposal Sites
<br />Description (Make/Yr., Color) ......... ... .—.
<br />FEE
<br />Serial No.., CAL. License No. _ _ _ CAL. Ucz7ise Renewal No.—
<br />_ ,
<br />Capacity Gal., Weights &Measures No. _
<br />AEMl T tED
<br />Equipment Parking Address
<br />A►iC7i.1NT
<br />2. 13 PUMPER YARD
<br />II!
<br />For July 1,____._ June 30,
<br />..�...._._..._._................
<br />No. of Vehicles Stored
<br />No. of Chemical Toilets Stored........... _._..
<br />j
<br />3. D PERCOLATION TEST
<br />R.S. or R.C.E. Name _ ..._._ R.S. or R.C.E. No. ...... _ _
<br />------....._4rj
<br />Test Location — _ _---_...... Test Date/Time ..... .... _.
<br />o, 0 SANITATION PERMIT ,, 1 ✓*. �3
<br />Sob Address -Lo
<br />OOrr
<br />EPTIC TANK CESSPOOL L'1 LEACHING FIELD 12SF EPAGE PIT El PACKAGE PLANT
<br />VPERMANENT C3 TEMPORARY NEW © REA�1R G OTHER
<br />5. © CHEMICAL TOILETS For July 1, - June 30, 19 � __ ``�. t; ✓
<br />�'
<br />Construction Disposal Site __
<br />_
<br />v. of Units -_.... ... _....... —_._-- Equipment Storage/Cleaning
<br />y
<br />$, 0 PACKAGE TREATMENT PLANT For�July 1, -June 30 '8.! _�_____
<br />C.'oerwor Name .____.. _..._,. ,_
<br />___ Where Certified -- ........
<br />vF I
<br />_.
<br />Plant Location
<br />Plant Capacity _-........ _ ___._..� No. Units served._ _ _ ..
<br />7. 0 LAUNDRY For Jut 1, - June 30, 19 _.-.__.._.__
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<br />SIZE: 13 Less Than 1,000 Sq. Ft., © More Than 1,000 Sq. Ft,
<br />0 DRY CLEANING, Chemicals Used/Amount/Mo.
<br />I hereby certify that I have prepared this application and that ,the work will be done in accordance with San Joaquin County
<br />ordinances, state laws, and ruiDerbrid regulations of thp San Joaquin Local Health District.
<br />APPLICANTS SIGNATURE
<br />- FOR DEPARTMENT USE ONLY
<br />C-': _., , .. r"'1 ,:,mea ,..u� I"`I rraa «�-r� 1 �xGH ❑ JaWuary 1 8 Aecevtad ev ih wary 31 .July 1 A ReLBived E;A11Y
<br />rcc w vuc. ,...., .,n.,•v..r......,
<br />...,, , ,..,.
<br />,..... ._ . __.
<br />-. ...............
<br />— � ___..
<br />BILLING REMITTANCE �
<br />3
<br />AMOUNT DUE
<br />f2EMiT
<br />CHECKEDNT
<br />FEE
<br />SASE
<br />t,�•�
<br />EXPLANATION?
<br />DATE DATE
<br />AEMl T tED
<br />J
<br />A►iC7i.1NT
<br />Ltrss
<br />PRORATiON
<br />II!
<br />-
<br />..�...._._..._._................
<br />._.
<br />PLUS
<br />PENAI Tv
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<br />H8S8iYA49 i7Y )die Receipt No P �c��,,.y.11�dd� ""Irl 0 0417 i�i513i@tt OBti tttl
<br />�— APPLICANT --RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PEAUrriB tiV_- "/" 1901 E. HAZELTON AVE.. P.O. SON 2M STO KTOM, A 95201 �..
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