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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,an-'Suspendable) SEPTACE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Apple-.atio Is her by e to carry � <br /> On b Ines in a)urisdictioral area of the SA a wn cal Health lstnct <br /> Business Nam (OBA) A�� Address � <br /> .�C�G///fJo TWO -- - - - --- <br /> `Owner `'C.s.K Address, /Z►s <br /> - - <br /> u Firm Partners. Addresses and T I hone Numbers <br /> 7VI .2 3// - --- -- ----- - -cq <br /> o <br /> a. Business Telephone 3 /"'_3S jj - Emergency Telephone No .S -_ - --- - ----- --r <br /> No. <br /> iContractor Licence No. ,4b-5 7J,f - - - Title Data <br /> Applicants Narne(Print) K tC�.__�F�4L --- <br /> Please check Applicable Category(1-7)and Fill In the Required information <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACI iCHICLE) Got- <br /> For July 1.- _ __. June 30. 19 .__ _. <br /> Disposal Sites _..-__.- ---- ---- <br /> Description(Make/Yr.,Color) _ <br /> CAL.License Rene"I No. <br /> _ - .---- -- <br /> Sepal No. ___ CAL License No. _ <br /> Capacity Gal..Weights a Measures No -- <br /> Equipment Parking Address ---- <br /> 2. ❑ PUMPER YARD <br /> For July 1, ._ __ June 30. 19 _No.of Vehicles Stored ------- --- --- - - - -- -- - -- ---- - <br /> No of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> F.S.or R.C.E.No --- <br /> R.S.or R.C.E.Name - - <br /> Test Location <br /> Test Date/Time --' - — —"— <br /> - - � <br /> SATATION PERMIT <br /> Job Address;LOcahon � G <br /> Owner E'-In ONN Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL `❑'ACHING FIEi D CkogEEPAGE PIT ❑ PACKAGE PLANT L <br /> ❑ PERMANENT ❑ TEMPOki qY ❑ NES\ Q.REPAIR ❑ OTHER C4 <br /> �,N <br /> 5. ❑ CHEMICAL TOILETS For July 1.-June 30. 19 - C'G <br /> Type Construction Disposal Site <br /> No of Units Equipment Storaqe Cleaning Location(s) T <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1. • June 30. 19 Whern Certified <br /> Operator Name <br /> Plant LocahOn <br /> No Units Jervell <br /> Plant Capaclt� <br /> 7. ►1- LAUNDRY Or July 1. -June 30 19 <br /> SIZE ❑ Less Than .000 Sq Ft. ❑ More Than 1.000 Sq Ft - <br /> ❑ DRY CLE%NTNG•Chemicals Used/Amount'Mo <br /> I hereby Certify that I hAVA pr B ;tied this apill n and t at the York will be delle In accordance with San Joaquin County <br /> G hlnnnces. State In n ,.Ili .end r llldi�UnC } S1 Joaqulr.Local Health District. <br /> APPLICANT S 2,''GNAT URE X <br /> ---- - -— - -- - - FOR DEPARTMENT USE ONLY <br /> 13❑ 1 A ❑ Ja„ I A nr,rr1 by Jnnla.y N <br /> Fee Is Due: A, v I'i n LINT ❑ PIn•. II lu'y I✓1 Rwr.,rwf Hy JWy l' <br /> REMIT <br /> IFI(LINC. Ht MIT TANCF 6 AMCt INT DUE CHECKED <br /> /IA I IlI•t ANAIIIIN DAIF DATF REMITTFL AMOUNT <br /> I <br /> I�E "1 _ r u�J (rte \V�d <br /> I L::S 't <br /> nE NaL Tv <br /> I IIn�Lu <br /> IL. '- I' ''• 1601 E HAM11Art AVE.KO '?.2" STDCK,1ON CA"Viii <br /> i APPLICANT "FTURN ALL I`PIF%TO FNVIaoNMr NTAL HFAL TH PERMIT '•[RVICES /�r7'�r�jJf �� �T1,� 1 <br /> — /11 <br /> / A <br />