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Aroltcxflon.Will rig Pr•jcessed When SuCmRled Pro"-ty Completed. Be SUto To SIp-T Tlwi Rp[MICANOa r. <br /> AM-1CATION <br /> (for Non-TraneferMA@-.Rovocable,and Suspendable) SErTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUI10 WASTE <br /> Application 14 here y made tc carry on but.ncsv In 1'oe;JnsdiClional area of tiv�on Jtr uln Local HNWh District Q <br /> RugineR�Name mnAI n A ffJortop� f SoAJSr ZA�I:... _ ._ Address <br /> i Owner-- __ Addrevs-- -- ------ - ------ -- <br /> Firm f`-rtnws, Add•assrs end Telephone Numbers — <br /> 3 Business Telephone No. <br /> Contractor Licence Ni. <br />_ ` Appiiunta Name(Pnnil STia�hl,5r -!Vi M-!5. _- —- _ ---._ Title Dole 4foo — <br /> Fit""check Applicable Cato dory (1.7)and fill M the Required hformaMon <br /> a ..•1 1. ❑ PUMPER VEHICLF.PEnMIT AC-GISTRATION(FOR[ACM VEMICL.E) <br /> For July 1,___- _ _ JUne 3). 19 .-____. . Disposal Site% <br /> ` Description(MskarYr.,Color)----__-_-_-_-._____ <br /> Serial No. - CAL.License No. -—__ _ __.-CAL.Lkw"RM+talrlal No._ <br /> Capl;,tty___-__.___. Oel rytsights a Measures No. <br /> Equipment Pihung Addroma _ - _-.__-- ------ ----- - <br /> t ❑ PUMPER YARD <br /> For July i,___,_ ,finely 30. 19 <br /> }y <br /> No.of Vehicles Stored --- �- -- - <br /> No.o1 Chemical Tothta Stored <br /> W a. ❑ PERCOLATION Te4T -` <br /> Test L,occ Ww ---.-.-__.-- _ _ --------- -- Test Data/Tlme_------- <br /> 4. Q SANITATION PERMIT / y <br /> { R Job Add,rre-ss'iL�occt�io�n <br /> Owner s�u�eevLAat1-�a�lv���- Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL HINO FIELD EMEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PEFIMANENT ❑ TEMPOfiAaY ❑ NEW Pr%EPAIR ❑ OTHER <br /> a'a( <br /> S. ❑ CHEMICAL TOILETS For Juty 1,-June 30, 19 ---___.__ I► <br /> Type,,onstructlon _ Disposal Sits _ <br /> No.of Unite -- _---_-----__- Equipment Storage,'Clsaning Loeatkon(s).- —_ __-- <br /> 6. ❑ PACKA7E TREATMENT PLANT For July 1,-June 30, 19 _ t <br /> x_ OpmtcrName -__-- --._ -- ---------------.--------------_—__-WhomCw"W - -. <br /> `• Plant l ochbon ___-- <br /> �t'yy Pmw Capacity_-- ___ _ _ ---No,Un is Served <br /> ►. ❑ LAJNL'Ry mor July 1. -.lune 30, 19_----__-- <br /> SIZE: U Leal Than 1.000 Sq Ft. ❑ Mors Tnan 1,000 Sq.Ft. <br /> ❑ DRY #LEANING.1-hamicals Used/AmcunVMo. _- <br /> rhe. i hereby c-lift' that i ha prepared this application at the work wit be dons 'n accordance with San Joaquin County <br /> f ordinencv-, stele InwR, rwea an ula o Jopquin Local HNlth Disulot. <br /> `.; APPLICANT'S SICri"URC X <br /> Sa 'F`✓ <br /> F011 OEF'MTiMENT USE ONLY <br /> Fee 1.Due: ❑ ANNUALLV ❑ PEn UNIT ❑ PER slfE ❑EACH _❑ 'awry r a Pecv and By January 3. ❑July r a Reca-4I By Jury 31 <br /> t y, Ir BASE IT ERPLAItAT1QN f <br /> AMOUNT DUf CHm'Cf(EO <br /> AMOUW <br /> .MTF. PATE REMITTED <br /> FEE <br /> LEIS I <br /> PENALTY <br /> PR \ L1 <br /> � <br /> OTHER <br /> t OTHERA�-2--- , <br /> orpw�;i.�a M o�,• i-#;r'4 i4o.— <br /> -, 40"k;Aw? off vlMw0ll rnntaTo ►wvIa0dOWSITALHEALTOP NafIff8-"It /t11 LMAULIONAMI, Illi rlae OMXr0le04Hall <br /> .. 4w- r.Y.P•i+:'v+5'H,,.'�s.,q,x.',�-.. :M a§�e; ,, : e,p �' + - � _g , <br /> s <br /> Scf� <br />