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Applications Will Be Processed When Submnled Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Trensfe►eble,Revocable,and Suspendobte) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 1I91.110 WASTE <br /> Applin-n!inn i9 herphy marip 1D Crlrry on bt»IneSS In the Iunidictionill area of the San Joaquin LOC81 Health DI!IrICt <br /> a 8toinn%j Nnrnp iDRAI /d, n,L,r y ANV y Sry Addrels DO' //O '-feernirr <br /> "lwner A. re /P.v/4 e- Address x"''1 two <br /> n Parinprl Arldrpl5es and Tplpphnnp Norrlb-tmi <br /> .liinell Tplaptionp No Jr.,J YR/ 1 Emergency Telephone No r1 <br /> Gonlraclor Li(enc.e No /F 4C - <br /> e Apphcenll Name Infill / r - nvTlO.,./ I'lle tA,,*IY"•T Is Y Dale <br /> Plsase check Applicable Category 14.7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE,PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1 June 30 19 Disposal Sites <br /> Delcrrplir�n(Make/Yr,Color) <br /> Serial No CAL LiCen"NO CAL.Lic;-to Perc^at 147 <br /> CApACity Gill.Wo,ghts 8 Messurel No <br /> Equipomot Parkrny Addre9l <br /> 2. ❑ PUMPER YARD <br /> For July 1. June 30 19 <br /> No 01 Vehicle9 Sloted _ ____ <br /> No of Chem Cal Toilets Slored - <br /> 3. ❑ PERCOLATION TEST <br /> R S or R C E Name R S.or R.0 E.No <br /> Test Location Test Date/Time _ <br /> 4. ❑ SANITATION PERMIT ' <br /> Job AddresvLocntion S ! -�. ),,,A M R el j /�•�N _ <br /> Ownera'�rry /a/r !-'/= nddrass 7t :l A x 7 S. Z✓o►ryovw <br /> ® SEPTIC TANK C) C,[SrP00L 20 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r,•, <br /> ❑ PFnMANENT ❑ TF_MPURARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For Jldy i -June 30 19 <br /> Type Construction Disposal Site <br /> No of Units Equipment StoragniCleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1 Juno 30. 19 <br /> Operator Name Where Certified <br /> Plant LOCAIIUII <br /> Plant Capacity No Units Served <br /> 7. ❑ LAUNDRY FOr July 1 -June 30. 19 <br /> SIZE ❑ Les% Thrill 1,000 Sri Fl ❑ M. rp Than 1.000 Sq Ft <br /> ❑ DRY CLEANING. Chomlcals Used/Amr)unVMO <br /> 1 hereby cartily thnl 1 hnvp preparodthis appiiCation and that the work will De done in at Ince with San Joaquin County <br /> tudinnnces,1tAte Inwl rind ruleg andrrequiatlons of the San Joaquin Local Health District <br /> APPLICANT 9 SIGNATLIRC X •.^'�ll� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: CJ arvp iM r• G7 i'I n i INTI ❑ 1'►11 nI If ❑ 1 M'i/ ❑ itiousey 1•$tw o,-"11t, io-w v}1 ❑ Jutr 1 A Itwr snM at, loin 11 e <br /> r a1Kitt r <br /> pn,1 I ithl ANA IION Ali.I IW1 IITMIT IANCEt AMOUNT DTII CG/ICKID <br /> nAtr a; OATF EMIT l AMQUNI <br />_ it <br /> , <br /> 51, <br /> 1•f HAI 1 Y \ r,/� <br /> rltlrl 11 1 7 \ I <br /> r.r,tl rr <br /> I 1 1:3 <br /> \.) <br /> ewrmn No N• �ncA AN 114ere0 bNwArM <br /> APpLrCAMT ATI1/pNAll CnprF;to 1•/YrnnNMrNt�I PIr ALI IP[alelT e[aY1C[[ IN1[ NA[[LTOM Airs.►O ep l►ee[ sTOCMTOM.CAN -- <br />