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Applications Will Be Processed When Submitted Property Completed Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non•Transterable,Revocable,and Suspelldable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTATE <br /> LIQUID WASTE <br /> A . lieat, s er mPPde to ea on busif!eas in ih jurisdictional area of the Joaquin�pcat Health District <br /> w Business Na (DBA)_ �r` m of-, eS)� Address .`?- � r.5✓S('btu fiyc <br /> iOwner._._. _�M C`r4AGl/C _, _ _ Address_. - ---- <br /> Firm Partners, Addresses and Telephone Numbers _22'. 634y --------- <br /> abusmess Telephone NoEmergency Telephone No -- -- <br /> Contractor Licence No. �y39/9 <br /> Applicants Name (Print) Title ____.____ Date --_ -- - . <br /> Please check Applicable Category(1-7)and Fill In the Required Informallon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) _ <br /> For July 1,_._.._.June 30. 19 Disposal Sites -_._..._� - - -- - <br /> Description(Make(Yr.,Color) _..__. --- - -- -- -- -- --- -- <br /> Serial No .____ __._ - __.. _-._ CAL. License No. _- _- __.___ CAL. Lic.tsa Redowal No._ <br /> Capacity __.---_--_ Gal..Weights & Measures NO. <br /> Equipment Parking Address -_ __ -- ------- ' ' - - "--- <br /> 2. ❑ PUMPER YARD <br /> For July I,___ June 30, 19No,01 Vehicles Stored <br /> No. of Chemical Toilets Stored ------- --- —'-'---" <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. NaR.S-or R.C.E.No. - <br /> Nam _ _ <br /> Test Location -- Test DateMme — - - -- -- <br /> 4. ❑ SANITATION PERMT�.y� n1 UJS OAC R O <br /> JobAddress/L.W.- b ---- ----------'- --" <br /> Owner .._.._` +� �--_ __-_ Address---- <br /> ED <br /> ddress --E' SEPTIC TANK ❑ CESSPOOL OLLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,- June 30. 19 <br /> Type Construction __ Disposal Site �6U0 Gr9/ <br /> No.of Units Equipment StorageiCleaning Location(s) - <br /> IL ❑ PACKAGE TREATMENT PUNT For July 1, -June 30, 19_..T <br /> Operator Name .. Where Certified --- <br /> Plant Location <br /> Plant Capacity No, Units Served -------- - --- - - - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE- 0 Less Than 1,000 Sq. Fl., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/ArnounuMO, __--_ - ---— -- -- " <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin Courlt <br /> ordinances,state laws, a^�las andregulationsof the fin Joaquin Local Health District. _— ' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNuauY ❑PER UNIT ❑ PER SITE ❑ EACN ❑ jar,",1 a Rwehw ey u+Nary 31 ❑ j.1,1 a aaL��.w at jo, ,. <br /> - <br /> BASE EXPLANATION 61LLING REMITTANCE S AMOUNT OVE CHECKED <br /> DATE ,GATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OnrEn <br /> s`f-n-'y L� l 33 _l�a �--- _ _ <br /> ReFMM I <br /> W Dal Race,pl No. Perm11 No cauanc 4 Medoa O£IYwretl <br /> APKICANT—RETVRN ALL COPIEe TS ENVMONMlNTAL HEALTH PERMITrsERVIC£4 NOI E.HA ELT v.0.ear <br />