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APPLICATION <br />!r ,. (For Non-Transfert3le, ResorabM, and Suspendabie) <br />ENVIRONMENTAL HEALTH PERMIT <br />!Y� Application Iher mad carry Dusinesy in t. patiaAfctional area of the Sa qi <br />fBusiness Name (DBAI. U h 1 t 3 Apdress 0 <br />i owner Eli'1, Iw PA -.K rad--, 7r <br />97 Firm Partners, Addre and Telep ne Num r�ss t <br />Business Telephone No.� -rcp 7 Emergency Telephone <br />1 Contractor Licence No. _ <br />Applicants Name (Print) 4 r [] Title <br />Please cheek Applicable Caf&aM (1-7) and Fill In the Requked Inlormadon <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />ForJW 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Colorj: <br />Serial No. <br />Capacity <br />Equipment .'3_nrking Address <br />2 ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No_ of Vehicles Stored _ <br />CAL License No. <br />Gal., Weights d Measures No. <br />SEPTAGE <br />Date <br />CAL Lkwm Renewal <br />/A�-l�''Jo.jof Chemical Toilets Stored <br />PERCOLATION TEST <br />a R.C.E. Name 2R.S. or R.C.E.No. _ R.C.E. 18 6 2 5 <br />Test Location _. 5 e_e�::tachi Test A te/Time <br />0. ❑ SANITATION PERMIT1'- <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK 0 CESSPOOL '❑ LEACHING FIELD ❑ <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ <br />& ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />Disposal Site <br />No. of Units Equipment Storage/Cleaning <br />IL ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 _ <br />Operator Name <br />Plant Location <br />Plant Capacity <br />7. ❑ LAUNDRY For July 1, -June 30. 19 <br />SEEPAGE PIT ❑ PACKAGE PLANT <br />REPAIR ❑ OTHER <br />No. Units Served <br />Where Certified <br />SIZE ❑ Less Than 1,000 Sq. FL. ❑ More Than 1,O0o Sq. Ft. <br />❑ �wr NING, Chemicals Used/Amount/Mo. <br />N AlaRher aiMdOit Ye.ipnen"n`e.yl»sV'°iono»a+q,^Ica'1[(v'hati' the pertcrm3ru0f Llswc:kfcrwbkhtMr permltla iawsd,Ishall nOtsm 1 a <br />_OlxOme suWtti It-orkman's cwaper,3aticn Ito ; a1 Cail:a-::i:r. D try ^Ypil,," <br />Ypenanaalibied to wwA as u� w pnwa ` n'�'T9 `" of Cao :,, ,."'3�'v4�e- -t cenily that in thompille performance Of it a wort' fur which lids Permit It ITauad, l shall <br />CWalfell;aden lays <br />i hereby certify that 1 have pre [h( applic tion and at the work wil'''l'''t>ee done in ac_•ordanee with San Joaquin County <br />ordinances, state laws, and rulgr� d ations of Joa uin h District <br />APPLICANTS SIGNATURE 'X fir//r <br />T� <br />FOR DEPARTMENT USE ONLY <br />Fee Ia DUC ❑ MNUAIA V ❑ PEA UMT ❑ PER SITE ❑ EACH ❑ J ,, 1 a Reoived 9y Jwow y 31 ❑ Jath 1 a R...d By Juy 31— <br />._ <br />--:VISE <br />EXPLAN TION <br />WTE <br />REM�IAANCE <br />REMITTED <br />DUE <br />REMIT <br />CHELXED <br />FEE <br />101's <br />5 c <br />es �s <br />as <br />LESS <br />- PRORATION <br />PLUS <br />PEtiAl71' <br />FiMI <br />Q\ <br />liT <br />OTHER — <br />-- <br />° S <br />17s-,1QJ <br />OTHER <br />.',renvx Sv 'Jam-- <br />Retx+oL N�. 'Srm,r Na. tsruae N'w Wiled [bfiveraA <br />