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COPY <br /> APPLICAT10i'd <br /> (For Non-Trainleril ie,Revocable,and Suspvridriblr.l <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Agpi;colicin is herety made to Carry an business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name ?t]f3A1 3�. fA�',�Ett�t! `,r•vS ___. Address .iH f>:�x /4!�� 7�'�✓-. <br /> Owner. Address <br /> u Firm Partners. Address+�s and Telephone Numbers _. -_---- <br /> rBusiness Telephone No_ Emergency Telephone No... <br /> ContractorLicenceNo. <br /> i �s�n.Tp�.... Dale - <br /> ----- <br /> �AppiicanisName(Print) ._._FC!`Y�._ L�`_oo�?--.- - _--_.. Title . 5- <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTZATION(FOR EACH VEHICLE) <br /> y For July 1. June 30. 19 __ _ Disposal Sites ------..-.-- <br /> Description IMake/Yr.;Coiorp-._----__ <br /> Serial No. _. _._-._ _— _ CAL.License No. CAL,Licensb Rene wat No. --- -_ C <br /> Capacity---- _ Gal.,Weights S Measures 140. <br /> Equipment Parking Address ._. ----- w -- - ------- --� -"'_--- - <br /> 2. ❑ PUMPER YARD <br /> For July 1,_.___ June 30. 19 . <br /> 'f'' r <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored. ----- ')-- T-®--- -- <br /> 3. ❑ PERCOLATION TEST d t <br /> a R.S.or R.C.E.Name ._ .. _ _ R,S.or R.C.0T1D. .._ - <br /> Test Location .. . _. -.- ...-.-----_--•---- ___ Teat Date/Time <br /> 4. 9 SANITATION PERMIT <br /> Job Addre"!Locatinn '17 3 /_ tr'1NE'A 2 7? <br /> Owner—RCA--+ •7-0 t.L!0r1fr _ _ _..-_.- AddreSs vrq rrov'_Leet..._ <br /> SEPTIC TANK ❑ CESSPOOL �I�r LEACHING FIELD JR SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY la NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1.-June 30, 19 .-__._•-_ t <br /> Type Construction...... --- Disposal Site <br /> No.of Units .:...__. Equipment Storage/ClePning Location(s) __._._-.- --- <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certllied <br /> Plant Location <br /> Plant Capacity_..._ __ ..._ .__._ ._._ n.__._-._._ No Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19__- <br /> SIZE: ❑ Less Than 1,000 Sq Ft., ❑ More Than 1,000 3q. Ft. <br /> ❑ ORY CLEANING.Chomicnls UsndlAmounl/tufo. <br /> I hereby certify that i have prepared this application and that the work will be done in accordan^e with San Joaquin County <br /> ordima,ins.slate Incas, ind rules and regulations of the oaquln Local Health District. <br /> APPLICANT'S SICNATI.MF <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANIJiIALLy ❑PER UNIT 19 PER SITE ❑EACH ❑ Jenuary I B Rnelved fly Jl+nuary 31 ❑July,a Rrcrn rd By July 1T <br /> If .—...__ ...._ - -•.-_ _.�.—. _._.._.._. __. _ REMIT"`............ <br /> - r BASF. I EXPLANATION PILLING REMITTANCE s AMOUNT DUE -CHECKED <br /> DATE DATE PEMITTED _ AMOUNT <br /> FEE t� L <br /> —a+D'.._..-�--- --�"- � <br /> _ . . _ i . ys. __ __ —_. - - -4. S– --- ---- <br /> LESS <br /> PRURATION <br /> PLUS <br /> PENALTY <br /> .r' <br /> OTIrfR...._.. - - ----- _..._. --- ^_^-- ---- <br /> OTHER .. - . . .._..... .-_._��_�.. --_.•--.._ _.____'.—_. <br /> 3 Aceivro ny rn,l No Uaua., Dm e <br /> 1x61[.NA=[LTON AYE.,P.O.5011 2M <br /> '+ APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMITIBERVICEt{ fTOC TON.Cil M11Y1 <br />