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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, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTA,GE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the-San Joaquin Local Health District <br /> Business Name(IDBA) _R07-0 7-eA. .....5 it <br /> AcIdress; <br /> 4) Address <br /> Firm Parsers, Addresses and Telephone Numbers <br /> Business Telephono. No. (0 Emergency Telephone No,_..... <br /> Contractor Licence No. <br /> Ap;!,ilanis Name{Print) 10j i1v Title Date <br /> Please check Applicable Category(1-7)and Fill in the Re ulred Information <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1. June 30, 19 Disposal Sites <br /> Description(Make.'Yr_Color) <br /> 1 N ......-CAL. License No. ................... CAL.License Renewal No. <br /> pp I y JG&I,,Weights& Measures No. <br /> uipfne'-%: arking Address <br /> 0 PUMPER YARD <br /> ........ <br /> ror JulyJune 30, 19 <br /> No.of Vehicles Store <br /> lNo.of Chemical Toilets Stored <br /> 'j3. '0 PERCOLATION TEST�,. <br /> IFI.S.or R.C,F- Name............... N. f1A. R.C.E.No. <br /> C:' ) - <br /> iTest LocAtion Teo 04110T1010 .................... ICA <br /> ...4. XSANITATION PERMIT 'A t <br /> !Job Address/Location........... <br /> ............ <br /> b <br /> Address; <br /> SEPTIC TANK 0 CESSPOOL 0 LEACHING FIELD 103 SEEPAGE PIT b -PA'CKAGE PLANT <br /> 10 PERMANENT 0 TEMPORARY 11 NEW13 REPAIR 0 OTHER <br /> s. 11 CHEMICAL TOILETS For July 1,-June 30., 19--.._,— <br /> ype Construction <br /> Na. of Units ..................—Equipment Storage/Clennirig-Lo&1440n(s). ........... <br /> • <br /> S. CI.PACVAGETREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> !Operator Name <br /> Plant Location ........... <br /> Plant Capacity No:Units Served^*- <br /> 7. 13 LAUNDRY For July 1,--June 30, 19 <br /> (SIZE: Less Than 1,000 Sq..Ft., n More-f Kat) l,*WWVt7TIN, <br /> DRY I LEANING,Chemicals Used/Amount/Mo. <br /> rr <br /> I hereby certify that I have prepared this application and1that the work will be done in accordance with San Joaquin County <br /> ordinances,state,laws,a an4requI40111 a. n Joaquin Local Health District, 4c. <br /> X <br /> 'APPLICA1iIrS!§IGNATURE ....._.................... <br /> FXIA DEP E-TFE tfrNLY irk <br /> MWy I'g Re"MW by jsousty 314 E3 JUIV 19 R",Pwod By JUly 31 <br /> IS DUt;❑0 ANNUALLY,. •t3.PER UNIT PER Sit"E I a EA'CAI is <br /> .................... IT <br /> HILUW., RIFUITTANCt: <br /> SAW—,—_'M"_'ATI0N-—. V out CHECKED <br /> DATE DATE., REM EtA AMOUNT <br /> Ffil, <br /> IPA <br /> LE1 -i.3' <br /> PRORATION 4 <br /> tfi�1!4_T� .............. <br /> HIER x -Z ��10 <br /> ............. 5, to ........... <br /> ft ........... <br /> by Rtcwm No. MA No 4 <br /> WAII CAPS"TO:" fhMROWARMTAL""LT#iPERMI'r>SERVtCES 16o1 E,m"EtT4=AVK�P.O.Sim 200, ST041 0.,1A%�201 <br /> N 4 <br />