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. .•S�\ �` � YtFr <br /> >L ty 1"11. I:r�AI it <br /> APPllcatlotn Will Be Processed When 9ub"fled Property Completed.Be Sun To Sign The Applicafbn. <br /> APPLICATION <br /> (For Non-Transfersbk,Revoceble,and Suspondable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica0orl is he y made two ca�rryy on business In the jurisdictional area of the S Joaquin LOCI Health DISVIC p - <br /> EBusiness Name(DRA) was-��Lv-r-= Atleress ,�:y� Ay <br /> Corner A�1._cu.G.e C1Z. Addressqf�L� r <br /> Firm Partnere,Addresses and Telephoneyp_ . <br /> eusinesa Telephone No. 7j'$'$ L_ Emergency TeNPhone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) A• Title _ _' Date r' !�• <br /> Please drat#Applicable Category(1-7)and FIB In the Requited Informalloo i <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For Jut/1, June 30.19 Dispos-al Shea - <br /> NscriPBon(Make/Yr.,Color) -- - -- r <br /> Serial No. CAL Llcertso No. -.CAL.IJoame Renewal No. ° + t p <br /> GpaUty. Gal.,Weights S Measures No. <br /> Equip tell Puking Address <br /> L 17 PUMPER YAAU vY,_ <br /> For July 1..t June 3D,19 <br /> No.o/Vettklss Stored r ,p <br /> No.01 Chemlul Toilets Stored <br /> 1. O PERCOLATION TEST ,, • �, i , `,�e'%C B y;'w:.. kd\ <br /> RS.or R•GE.Name R.S.a R.C.E No.� f <br /> .Test Location Teat Oate/Thaecc- <br /> a. O.SAINTATION PERU <br /> IT r <br /> Job Adtlrr_v/Location <br /> owner _AfAgyAedr.re •�frG.es/ rrs e' <br /> ❑ SEPTIC TANK l"Lf CESSPOOL E3 LEACHING FIELD- .C3 SEEPAGE PIT 0 PACKAGE PLANT• <br /> PMMAETi TEMPORARY _ REPAIR O OTHER❑ <br /> S. 13 CHEMICAL TOILETS For July 1, .1e 3.0.19 <br /> Type COMhlKtlort - ..,. '" Disposal Sitr <br /> m:rW T({+Fe <br /> Pb.of Units' r' .. - EqulpmeM Sbrage/Gaaning Location(s) <br /> [. 0.PACKAGE TREATMENT PUNT For Jul• 1,-June 30,19 ... 1, � pt0'.N <br /> When CertlfkId(... kyrn`.` <br /> -OPeraWr Nems — #r-',K(tt!+S3rsVY,.:'-. <br /> Plant LOtation No.Units Served_....--- (:*iZS-7iJ1rffi.>Rblf iLi.E: 1 <br /> Plant C4W&cI y - s y un F <br /> 7. ❑ LAUNDRY•For July 1 •June 30.19 <br /> S:Zf• -❑ Lasa Than 1.000 Sq.PL, O Moro Then 1,000 Sq.FL <br /> 0 DRY CLEANING,Cherteeab Used/AnlounUMO. <br /> tl <br /> I hemby cartity itutt 1 have prepared this a Plication and that the work will be done In accordance wllh Sen Joaquin 6o6-' ) „n <br /> Winances,stare laws,and rules anJ rep Tay. . the San oaquhl Local Health District." •., , I : ;i '14q?�, nn ;, <br /> R PPLICANTS SIGNATURE <br /> Fee M Dur.O ANNUALLY ... ❑pq way- ,. CJ PER SITE 13 ERCP TSS NN I A Rs<erra By Js ,v 71 - ❑July 1 a� X "9X f� <br /> •., R¢Ileeb N - Rx <br /> BIWNO REMITTANCE E �AMOJNi DUE '1Cr1EGM�p;.✓ d <br /> SAX E1tPlANAT10N.. , PATE - DATE REM�iTED 5 ArpUNE{xt 5I . <br /> FEE <br /> _Y <br /> - <br /> .. _ .. .._ <br /> OTHER -� <br /> ibcwwa M------------------- <br /> — c«N Ha --pFi,.l�r o. �I�iwcaAM O .1w <br /> ArellCAMr�KR,Arr ALL CCeOTq: eNValPleaOrTA:i14L1H rlM1lTItalMtea ! MIl1MaaYOM AYe..aA.M>OIe. .t C[Tar5U4Mt <br /> -°"�tYW,',tY}�i�'+�j�'i;�'�.31.�i':JY�+"' �'_...._. _ .._. ._, .....-�+..:++cf .+:ewvx;aJnAw+x•.h.YMrhlwT'MaUMVKr:.LCFis<A.w+» rxr.w•+•.•�`v <br />