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(< AppllGatlOn►Will be Y104:e06*0 Wnell autsmitiou ...�•. •.•• _ , -- APPLICIMON (For Non-Transferable.Revocable,and Suspendable) ENVIRONMENTAL HEALTH PERMIT LIQUID WASTE Application Is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District usiness Name(DBA) 'D.A+ NrltkISN a' Z0-VS Address PCIBOX wner Address V rm Partners dresses and Telephone Numbers usiness Telephone No 1046 • 9(.07 Emergency Telephone No :ontractor Licence No. PI-V 3643 ,pplicants Name(Print) FL-OYP LNeo l? Title s T/M�lT1JQ Date L3"33'7 9 'lease check Applicable Category(1.7)and Fill In the Required Information . ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) or July 1. June 30. 19 Disposal Sites )escnption(Make/Yr,,Color) u ierial No CAL License No, CAL.Llc_-:e Renewal No (� rapacity Gal,Weights it Measures No \ quipment Parking Address 2. ❑ PUMPER YARD For July 1, . June 30. 19 ' No of Vehicles Stored --------------- No of Chemical Toilets Stored 3. ❑ PERCOLATION TEST R.S.or R.C.E.Name R.S.or R.C.E.No , Test Location Test Date/Time 4. B SANITATION PERMIT I Job Address/Location A{rOr N. TA c4c-re ✓G At]> O Owner F0P*0/AN0 60Address PO Pse" 4 39, L/POEN 9S- -2"" 9f SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT OtPERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER S. ❑ CHEMICAL TOILETS For July 1, ,June 30. 19 Type Construction Disposal Site No of Units Equipment Storage/Cleaning Location(ii) r 6. ❑ PACKAGE TREATMENT PLANT For July 1,•June 30. 19 ' Whore Corti Operator Name llucl h Plant Location Plant Capacity No Units 5elvod 7. ❑ LAUNDRY For July 1, .June 30, 19 SIZE ❑ Less Than 1.000 Sq FI. ❑ Mora Than 1,000 Sq FI ❑ DRY CLEANING.Chemicals Used/Amount/Mo. a 1 hereby certify I"I I hav apaird this application and that Iha caulk will be duns in st.LUrdarlLr with San JUaqulrl County ordinances.stat.laws. ruhr,'rnd regulations of the San Jeagwn Lu(.41 Health D1s111ct } APPLICANT'S SIGNATURE X + FOR DEPARTMENT USE ONLY Fee Is Due:❑ ANNUM LV ❑ 1'1 H UNII (7 1'111).111 ❑1 ACII ❑ J."'.." I A Nle a•r•1 till ❑ J.d/ 1 �Iia•rnW Nr lvN +� NILN+ RASE tXPLANAI4)N IHIIWU IILMIIIAN(a I AMOUNI UU1. Clot(►tb nAlt IlAtt NEM111t11 AM1)UAt y FEE �f j nl J i. t 7 LESS / PRORATION PLUS PENALTY 1 •,`1✓ .r�� I � OTHER i ! He.r,rnJ Pr Nr.v 10 Nu 1%,md No Irrur•Kr Ur Mrdwl >,r.,.r I - L. t AP►IICANT-RtIUNN All COP"i0 tHVIRONMENTAL HEALTH PtRMll 6t RVICE► 1601 E HA LY AVE YO cur JW$ ►I OCR IOM.CXl;`� .e 5 Vq..