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,,� .,""""...,_..� __ APPLIGA I IUM <br /> t°. SEPTAGE <br /> (For Non-Transferable,Revocable,�20 <br /> and Suspendable) <br /> ENVIRONMENTAL WASTE TH PERMIT <br /> ^ Appticatlo is ere made to Gar on business in the urisdictionaA��aof th San Joaouin Local Health District <br /> If <br /> r Business Name (DBA) Address <br /> Owner <br /> 1 Firm Partners, Addresses and T@Ig hon�ee Numbers Emergency Telephone No- <br /> 9: <br /> o.a Business Telephone No. �I <br /> Contractor Licence No. Title Date <br /> 1' <br /> Applicants Name (Print) <br /> ry(i-7) and Fill the Required Information <br /> Please check Applicable Catego <br /> 1. [1 PUMPER VEHICLE PERMIIT REGISTRATION (FODisR oEaACS VEHICLE) <br /> sEHICLE) <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) ' CAL. License Renewal No. <br /> % CAL. License No. <br /> Serial No. �— `— <br /> Capacity --- -- Gal.,Weights&Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 191i <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored I� r <br /> ` 3. ❑ PERCOLATION TEST �I R.S.or R.C.E.No- <br /> R.S.or R.C.E. Name If` <br /> Test Location ` <br /> Test Date/Time <br /> 4. )M SANITATION PER IT .1y - r <br /> Job Addr s! ocatio�ny Address - <br /> Owner_ F-/ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1 SEPTIC TANK ❑ CESSIPOOL I0`NEW ❑ REPAIR ❑ OTHER <br /> �TPERMANENT ❑ TEM"ORARY <br /> 5, ❑ CHEMICAL TOILETS ;kor July 1,-June 30, 19 <br /> :�M: Disposal Site <br /> Type Construction <br /> No. of Units 11 Equipment Storage/Cleaning Location(i) <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> IIMi. <br /> Plant Location No. Units Served <br /> �. Plant Capacity - <br /> 7. ❑ LAUNDRY For July 1,,;_-June 30, 19 <br /> SIZE: ❑ Less Than 1,000' q. Ft., <br /> ❑ More Than 1,000 5q. Ft. <br /> ❑ DRY CLEANING,ChemicJs Used/Amount/MO. <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> nd regulatio s of the San Joaquin Local Health District. <br /> ordinances,state laws,and rules a , <br /> I!. <br /> APPLICANT'S SIGNATURE X <br /> DEPARTMENT USE ONLY <br /> Ilf l FOR DEP ❑ January i&Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due:❑ AN14UAL`IILY ❑ PER UNIT ❑ PER SITE ❑ EACH REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1BASE EXPLANATION DATE DATE REMITT AMOUNT <br /> FEE <br /> LESS II I <br /> PRORATION 19i <br /> F <br /> PLUS Il <br /> PENALTY 1 + <br /> OTHER ill <br /> OTHER ill' <br /> I �. {nuance Date ailed elivered III + <br /> PII Date Receipt No. Permit No. <br /> Received by IK 1501 E,HAZELTON AVE,P.O:Box 2009 STOCKTON,CA 1 <br /> APPLICANT—AFTufm ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES — <br /> I <br />