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r <br /> - <br /> Applications Will Be Proceased When Submitted Properly Conpte4A.Be Sun To Sign The ApplbMipu - <br /> APPLICATION i <br /> S (For Non•TnrtsNnbN,Revocable,"SuspendaWa) _ <br /> _ ENVIRONMENTAL HEALTH PERMIT SEPTAGE ) <br /> LIQUID WASTE <br /> ADWIceO tro y aw to Corry on Dui in lhejurisdictional area of the Sant quirfilL I 'f9 Ct 6 '< <br /> �Businese Na ) _ Address441 <br /> Owner___ _ _. AAtlrese .- n <br /> /s Firm Partners, Atl ONS"an alephale Num _ <br /> Business Telephone No. _ _Emergency Telephone No. <br /> •1 Contractor Licence No. _C <br /> iL Applicants Name(Print)__ _ This — Date <br /> Pe elteelt ApplkaWe Category(1•T)and FIN M NN RequNW Inlornutlon <br /> rov <br /> 1. ❑ PUMPER VENICLS PERMIT REGISTRATION(FOR EACH VEHICLE) 0 <br /> For July 1,___June 30. 19 Disposal Sites <br /> Description(Maker.,COW) _ J <br /> Serial No. _ CAL.License No. CAL.Licence Renewal No. _i <br /> Capacity _ ._ Gal..WeiglSh&MCNsuros No. <br /> Equipment Parking Atldrosa <br /> T Z. ❑ PUMPER YARD <br /> For July 1,___ June 30, 19 �_ O <br /> Noof mica Stored <br /> Chemical <br /> No 01 Chemcal Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> lit.or R.C.E.Name_ R.S.or R.C.E.No. <br /> Test Location __ _. Test Date/Time <br /> a. ❑ SANITATION PERMIT -- <br /> Job Aodrea4l tion— Dl <br /> ppO��w __ Address _ <br /> It <br /> SEPTIC TANK ❑ SSPOOL LEACHING FIELD 136 ❑ PACKAGE PLANT <br /> m PERMANENT ❑ (EMPORARV NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-Jt a 30-19_ <br /> T _ -- ----- -_--- <br /> Type Construction Disposal Site <br /> No of Units . Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1.-June 30. 19 _ <br /> Operator Name -- _ _--_-___. _ _. __._._____. __._-_ --Where Certified <br /> Plant Location <br /> Plant Capacity _.___ - _ _. No.Unita SerYM ___._.___.___._._—.__.____.___—_ <br /> 7. ❑ LAUNDRY For July 1,.June 30. 19 ._ <br /> SIZF ❑ Less Than 1.000 Sq Ft ❑ More Than 1.000 Sq.Ft. <br /> ODRY CLEANINGChemiceeUsed.Amount!Mo <br /> I hereby :artily that I have prepared this application and that the work will be Cone in Accordance with San Joaquin County <br /> ordinances.Hate laws.an rul ntly�/JjP�lulahon o e San Joaquin Local H tin District. <br /> APPLICANTS SIGNATURE X � /! Z..Q^•C-� <br /> FOR DEPARTMENT USF ONLY <br /> ice b Dov!❑ ANNUAL.• ❑ill OR IN n%,if O 1 Acr. ❑ M"i". s r...... Cl r rev To, <br /> REMIT <br /> 0111 INC. REMITTANCE 1 <br /> RASE UrI ANATION pAif nATf aFM�ripp AMViINi❑lIF CHECKEO <br /> �j �•//- // AMOUNT <br /> TEE �7 S `�•S a�s� <br /> LFSS JJJ <br /> IR )RA•r1N C' •� qo <br /> I <br />