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Apnlle.•;ons Wnl Re Pr-ceased When SubmM ed Properly Completed. Be Sun To Sign The Application <br /> APPLICATION <br />'+ (For Non-Tranolwable,Revvfeable,and SueprndaDN) 11E,11 A,'r <br /> ENVIRONMENTAL HEALTV: PERMIT <br /> UQW0 MATTE <br /> _ Appbcahon ',--v to carr/Cn b jsmtss a1 the lur'sdictional area of tho Joagwr Local Health District <br /> Busmes, Nan,e IDPAI /��/? �I'rt('lS/f _ _--.__ Address i 0• <br /> Owner Address -- <br />: U- Firm Partners Adri—n- ,;anr, N. Numtkrs r <br /> p 5'h C �6 7. Emerpenc,Telephone No. <br /> Business Thle hone No —_— .—_.___ <br /> Contactor Licence No — ___ _ <br /> 4 Applicants Na-r,e(Priv', /�G c _-- Title DAN�7vfa <br /> e+ P4►eee Cheek Applleeble Catoq,iry(1 1 Fill In iM, aired htlq 00;ii <br /> 1. ❑ PUMPER VEHICLE PFnMIT RCL;i'c—DATION(FOR FACH VEHICLE) O <br /> J► For July 1. June 70, 11+ Dlspossi Shea .-_ <br />` Desch- On(Make/Yr.Color, <br /> Sensl No. _ CAL LWww No. ---- --CAL.Lloanaa 11wnwM No, i <br /> Capacity <br /> Equipmort Psrki:ip Address <br /> 2. ❑ PUMPER YARD <br /> For Ju,/ f,_ .-- :une 10. ll <br /> No Of Vehic*s Stored - <br />,ra�, No. Of Chemk.al Toilets Store,) <br /> �. ❑ PERCOLATION TEST <br /> R.B.or R.C.E.Name —- - - .--.- ------R.S.or R.C.E.No. <br /> Test Lxstion �-----_.-- ___.__.. Teal 0at++a/'TM►e <br /> A. JIB SANITATION PERMIT _ _.-- _... <br /> Jon Addrees/LoGltion 342 y7- -- <br /> ❑ SEPTIC TANK ❑ CES SPOOL p LEACHING FIELD B SEEPAGE PIT 0 PACKAGE PL WT <br /> ❑ PERMANENT ❑ TEMPORAnY ❑ NEW JO REPAIR ❑ OTHEA ' <br /> E. ❑ CHEMICAL TOILE i b For July 1,-June 90,19 _ <br /> Type Cw aftuekn— ---- — Dtspoael S110. _ <br /> No,of Unit ___-__ Equipment Stogy Llxatlon(a) C <br /> S. ❑ PACKAGE TREATMENT PLANT for July t,-June 30.19 <br /> Opwalor Name ---_---. ---.. — When Cet"RW _ <br /> Went Loeatio•� --------- _ __——. _—�-- — <br /> Plant Capacity—___-- _ __-- No.Unita Sewed <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19_ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft, ❑ Mon Than 1,000 Sq.Ft. <br /> ❑ oar � s Used/AmOunt/MO. <br /> alattner n fa n.c.+M,*''x1t�„ra'';;��'��'•�"'�`1�tAa•1nM!v�►hna.nwef ekwo►Rror wRkn elb pweWrls lssoeo.l snaf►na Navlbr2111►Irerfo. <br /> OaIIMMlaer AMAr u. .ulr--.m.e.►A� dt+�xl�aNh1 101tit Calrte+ala.- <br /> MMII wr1}sq b M�.lrnya►ce,,,p�etaw"It Q C�Oi ah.ft'��4 1 LwthY M►.!in tit OMonaantx of the tvatl fa wt tic IMS pare h bailie(sB� <br /> 1 h raby certify that 1 have prepared this application and that t1N vrork will M done In accordance with San Joaquin t•ounty <br /> -rJmallces,slate lawe and rule„and ulatb t t Sen Joaquin 1 ocal Health District. <br /> APPLICANTS SIGNATURE X01 <br /> --- -- -.f <br /> FOR DEPARTMENT USE ONLY .. , <br /> Fee to C Je' ❑ ANNUALLY ❑PER uwT ❑PER siTE_ ❑EACH O Jwawy/a Awshvd By Jaawry 31 ❑July t a Recowad SF July 31 <br /> - I BASE E7tPLANATION -—RILLINO A11110111-TANCE a AMOUNT am dACNfD �. <br /> <. DATE DATE lel 1177 { <br /> A40u/tT .>S, <br />_ Ir <br /> LESS <br /> PRO0ATION '� ( ✓ ' <br /> PLUS <br /> OTHEm <br /> OTHER <br /> f. <br /> Wts.v«I DI I7�Ie - ---A c*ipt No Pwm.t N6 1 nae le <br /> A►PLrCANT-Ir"VIRM ALL COPIESTO' EN1r1eoN«ENT\L NEALTA Pt RUfT/UPVWEs 1001 e.NA2aLTON AM P.O.0011 ales sToelcTaa CA 016111 <br /> 4 <br /> I <br />