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Appticabom WIN Ea Pracassed When Submitted ProParhr~ B*Sure To ftn The Applkation. <br /> APPLICATI N <br /> �' r< (Far pion-Tranalerable,Revocable,and Suapendable) SEEPAGE <br /> �V ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUIIf WASTE <br /> Application to hereby mode to carry on twainam in the Jurisdictional area of the an Joaquin Local Health Piet cl <br /> a Business Name ;DBAt LF_F Fi Fir[_��1�C)C !�r_ _ Address <br /> Owner_ � V�I 1 l 1 WALA Addres6 -S _----�- <br /> u Firm Partners, Addresses a d elephone Numbers <br /> Business Telephone No. ErnoWncy Telephonla NO. - r- <br /> Contractor Licence No. <br /> Applicable Name{Pnn1} L W a►�� tt� �� ,__ Tfpla L-' Dew <br /> Plasm dmck Applicable Cd*gM(1-7)land FW in#w Reglllnod Infafmolkm e <br /> 1. ❑ PUMPER VEHICLE PER1r11T REOiSTRATION(FOR"CH VEHICLE) 4— <br /> For July 1, June 30. 19 Dlepoeal Sites <br /> Description(Mak*Nr..Color) -- <br /> Serial No. _- CAL. Llclanee No, CAL LlClaean Rane"Ntl. <br /> Capacity Gai.,Weights & Measures No. — <br /> Equipment Parking Address— — - <br /> 3. ❑ PUMPER YARD <br /> For July 1, June 30. 19 No.of Vehtcles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R S or R.C.E. No- -- _ <br /> Test Location Test DatelT+me _ <br /> i. ❑ SANITATION PE(t`+T � <br /> Job Add_ Lo tlan J - <br /> Owner- ?'' X tom,L A" W Address r) 1�3 N <br /> Ez- <br /> 0 SEPTIC TANK [) CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPoFARY Ej NEw � REPAIR ❑ OTHER <br /> & ❑ CHEMICAL TOILETS For July 1,-June 30, 19_ <br /> Tyke Cormruction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKA09 TREATMENT PLAW For July t, - .June 30, 19 <br /> Operator Name where Certified <br /> Plant LOC6lion r <br /> Plant Capacity- No. Units Served <br /> T. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft_ ❑ More Than I.ODO Sq. Ft. <br /> ❑ IDRY GLEAMING,Chemicals Used1AMMirittlho. <br /> I hereby Cer y have prepared this applicatro and that the work will bB done m accordance with San Joaquin County ~* ~ <br /> ordinances,slate law ,a rul sand1agul ran o1 i>a aaq n Local rtealtn District. <br /> APPLICANT'S SIGNATURE <br /> r <br /> D <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANw4ALLY 0 PER uNiT ❑ PER SITE ID WH ❑ J4mwy t 1L RscumW By isms ry 31 ❑ yuiy i a Reee.reo By July 31 <br /> ,45Al <br /> BASE F]iPLANATIpN BILLING <br /> _DATE iIElAITTFA E I1I AQunr DUE C <br /> DATE HI <br /> NTZ <br /> FEE I L '_ s'l L <br /> LESS <br /> PRORATION <br /> PLUS T <br /> PENAL TM <br /> OTHER <br /> OTHER <br /> i lay Na wane No r"'Difts F"116d cW <br /> ICMMMa-IIe7111M At.a"M T* UNVOMIWWffu MA1.11I Pa WIF/alallvrcu 101 e_HAULTow AVE.,P.C.a.s 11010 etaCKTOK Ca gigot <br />