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+r <br /> a <br /> fry �:. - ,_• ... ... <br /> Applications WIII Be Processed When Submitted Property Completed.Se Sure To Sign The Application. y <br /> APPLICATION <br /> (For Non-Transferable,Rsry cable,and Suspendable) / SEPTACE , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h b ME laid carryon business in the lurisdictiona!area of the San Joaquin Local Health District i <br /> Adore <br /> IS Business Nsme (DDA)— j__ G G� s_L��–�•'ts'7L"&'y �TtA <br /> Owner y•!/eSJe. — Address — r <br /> 1 y r, 'r:Partners,Addresses and Telephone Numbers g„ <br /> E-ainess Telephone No. —pJ-Gf Emergency Telephone No. <br /> 99�L r <br /> �.1 Contractor Licence No. / 3- �'.�_OCJ- •, <br /> Applicants Name(Print) �A «uu� Title <br /> Pleaw check Applicable Category(1-7r)and Fill In the Required Information - -:' <br /> r 1. Q PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For Jury 1, - June 30,19 Disposal Sites <br /> _ Description(Make/Yr.,Color) CAL.License Renewal No. <br /> .` Serial No. CAL License No. <br /> -- - Capacity- Get.,Weights d Measures No. _ <br /> Equipment Parking Address <br /> -'. 2 Q PUMPER YARD <br /> For July t, June 30.19 go <br /> .NO.Of Venicl"Stored <br /> _; No.of Chemical Toilets Stored _ <br /> ,:r9.- ❑ PERCOLATION TEST _ - <br /> .i R.S.or R.C.E.Nam_a R.S.or R.C.E.No. <br /> :Teat Location Test Date/Time yv <br /> SANITATION PERMIT' aa� �� Ngo^—� ✓ t <br /> tr `Jo ADorn9Location ? <br /> -�OLZ'ne+` ^'C3`dG� TO<'Tr Address <br /> ' <br /> ❑ PACKAGEPLANT I- <br /> -SEPTIC TANK- Q GESSPOO� CK LEACHING FIELD ❑ SEEPAGE PIT Q OTHER <br /> JOIE' PERMANENT� Q�TFMPORARY NEW Q REPAIR <br /> n•i <br /> `S Q CHEMICAL TOILETS 'Far JuIY 1,`June 30. 19 <br /> Type ConaviicUoR' I ,. Disposal Site <br /> `No of Units - i Equipment Storage/Cleaning Locations)—_ - k <br /> s Uni - <br /> '�e Q PACKAGE TRFJITMENS'PUNT For July 1,-June 30- 19 <br /> --t-. <br /> -J _ Where Certified 'w <br /> t.::--Operator�Ni2na=,. <br /> ,ll Pient Location <br /> T ? i T - N0.Units Served ;. <br /> PINt Capxl fy <br /> LANNPRY 'FAr July 1.-June 30.19 <br /> -.r- .Q More Than 1,000 Sq.Ft. <br /> SIZE. Law Than 1.000 Sq.FL. <br /> CLEANI4^,^hemicaic Used/Amount/Mo, j QDRY <br /> - <br /> - _ , y <br /> ^ <br /> I hereby certify that I have prepared this agpnoabon and that the work will be done.m accordance with�a2 Joaquin County <br /> ordinances,stale laws,and rul�d fBgu i�f f tn Joaquin Local Health District. <br /> .Arlr,45K <br /> APPLICANTS SIGNATURE X —vim- <br /> FOROEPARTMENT USE ONLY <br /> FN le Doe: [3 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAOH Q Janmq't a Roca rN BY JanWrY]i t7 Jul, 6 RKAv EMIT Jul,]l <br /> BILLING aENOTTANCE S AMOUNT DUE CHEJCEO <br /> BI4E_ I EJ(RLANATION DATE - DATE REMITTED <br /> FEE <br /> j]y <br /> uss <br /> '. <br /> MOMTION _ <br /> FLUS _ L - <br /> PENAL� . : <br /> • OTHER <br /> _ <br /> 1 OTHER <br /> 11RM60 OY DLN R�CwPI NO Vl,mi HO. ISYWMe OeI!' WMee DN,Ane ... //• <br /> �: yRLIWrT_11(TYRM.LLI COIIEa TQ EMVIROMYFNTlL NE11LTN <br /> i51e1 <br /> REPIiTISERVICES 1601 EHAZEiTON AVF_V.O.O..]WS STOLIrOM.C.L -Y•( <br />