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Applications WM Be Processed When SubmItted Property C mp*W,Be Sure To Sign The AppNoatiom <br /> APPLICATION <br /> (For•Non-TWOtsraW,Fiftoc",and Susie) <br /> 4 - ENVII ONMENTAL HEALTH PERMIT SEPTA <br /> LIQUID W"TE <br /> Application ereby made r on-bosiripss in he Jurisdictional area of the San oaquin Local Health Distri <br /> ;s_,,siness Na (DBA) Addie g'''L 7a� <br /> Owner_- Address – � <br /> Firm Partners,Addresses a Tei hone bars <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. A' <br /> L Applicants Name(Print} Title _..�— Date ' <br /> Plea"Cfwt*ApplIeWIt Catepttr(1-7)end Fifi In the Recgiretl inforrrr� <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30,19 Disposal Frites <br /> Desctiption(Make/Yr..Col!*W� _ _• i <br /> Serial No. CAL.License No. CAt,.Ueense Rene"Na. <br /> Capacity tial..Weights d Measures No, <br /> Equipment Parking Address 1 <br /> 2. ❑ PUMPER YARO <br /> For July 1, June 30,19 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored Y <br /> 3 ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name_ RS. R.C.E.No. <br /> TestLtion __ Tess Date/T( <br /> s. (F SAWTAT(ON-PERMIT �. ....«.. ;�.-...-�...:.7 ,. .. . w. . .. Y.�. . _ ,,..,.. t <br /> Job Address/ do I r <br /> OwnerAddress <br /> ❑ <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD 06SWAGE PIT N ❑ PACKAGE PLANT � <br /> ❑ PERMANENT d TEMPORARY C] NEW Ck'kgPAIR C3 OTHER `J <br /> S. ❑ CHEMICAL TOILETS icor July 1,-June 30, 19 <br /> la Construction Disposal Site <br /> of Units Equipn4nt Storage/Cleaning L'ocation(s) <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Oper'aw Name Wtae�re�Gartlfied <br /> Plant Location <br /> Plant Capacity ' No. Units Served <br /> " � . i <br /> T. C] LAUNDRY For 1,-June 304a <br /> �.,u. . <br /> SIZE: ❑ Less Than 1,560 Sq.Ft., •❑ #Aore Ttj•an 1,000 Sq. Ft. -- <br /> ❑ DRY CLEANING,Chem"li-Us&WAn UnVMo, <br /> item ewrw oritmeeaedaclellt's �S{ifnR c"l�tblKinitte�otdrew�kfitrwhitS It Lbls�I16,It trete loys�i tIMA <br /> In means as to became t�raltun neeaialt laws N arnia.' <br /> canba coWs Ithing or elw"twi'e Ix►r fas tAe tedia%tow "I ortity duft in the perlarrnance of star work for wbtch this WmA n bareQ J s " <br /> eampiey persoae sutJW to vserkmaWs ompa=IW.I Ian atCg aiaia." t <br /> I hereby certify that I preparad this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state iawsXruies and regu tons of the San Joaquin Local Health District. y+ <br /> APPLICANT'S SIGNATURE XOp <br /> + <br /> :y <br /> 1 <br /> FOR DEPARTMENT USE ONLY i <br /> FOOD le DUO.L] AMUALLY 13 PER k"T © PER 857E *C]EACH 0 janywy 1 d Reeeiver7 BY JaaWAMY 31 ©.tiny t a R.we vec ey July 31 <br /> FWW <br /> eILUNO MWITTANCE 1i <br /> SASE EXPLANATION DATE DATE pE1v1tTTED AMOUNT OUE C"90 <br /> AMOUNT i <br /> FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTYOTHER <br /> . t <br /> 1 <br /> OTHER <br /> 3 <br /> Received by bale Receipt No. Permit NO malied De1NW46d <br /> • APPIJCANT_ranv 1N ALL t,OP10a TO: e m 1akTAL"MTN P67Ot1TAwRvjM =1416/E.NMELTON Alit?.,".eea'0000 STOCKTON,CA 001 ` <br />