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Applications Will Be Processed When SuAPPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) gEPTAGE <br /> ENVIRONMENTAL WASTE HEALTH PERMIT <br /> Appllill <br /> icat'on is hereby e t carry o busin sin the' 'sdic o;. Address <br /> l area of the S n�_guin.L fel alth gistr t <br /> �,�� vW+ <br /> wBusiness ame (DBA) h Address <br /> aOwner C I <br /> j Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Titl Date �. <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill In the Required Information y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) . y <br /> For July 1, <br /> June 30, 19 Disposal Sites A <br /> ti <br /> i Description(Make/Yr., Color) CAL. License Renewal,No. ` <br /> KCAL. License No. « <br /> Seriai No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> •` <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name i Test Date/Time <br /> I Test ocation <br /> 4..,F SANITATiON-PERMIT <br /> Job Addr ss/Lo ation 1; �+ <br /> Address ❑ PACKAGE PLANT <br /> Owner ❑ LEACHING FIELD El SEEPAGE PIT - 0 <br /> I <br /> 11 SEPTIC TANK [3 CESSPOOL ❑ REPAIR ❑ OTHER <br /> ❑ TEMPORARY ❑ 'NEW y i <br /> 1. ❑ PERMANENT 1 ra <br /> I -June 30, i9 <br /> $. ❑ CHEMICAL TOILETS For July 1, <br /> Disposal Site <br /> Type Construction _ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 1,-June 30 i9 ; 1 <br /> 6, ❑ PACKAGE TREATMENT PLANT For July Where.Certified /) <br /> ( Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> i 7. ❑ LAUNDRY For July 1, -June 30,`19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., [1More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> ej �I hereby certify that I have prepared r his latioins plication <br /> San Joaquin Local lHealth Distrill be done inct <br /> ,accordance with San Joaquin County <br /> ordinances, state la a d rules and_ i <br /> I 'APP II SIGNATURE"' <br /> I t FOR DEPARTMENT USE ONLY { t <br /> s REMIT <br /> Fee IS DUE: ❑ ANNUALLY ❑ PER UNIT 8 ❑ PER SITE EACH REM�TANCEy, 31 <br /> $Rec $'By January 31AM0❑TJDUc &ReceiCHECKEDed By y <br /> { - BILLING REMITTED AMOUNT <br /> BASE EXPL NATION ,f DATE DA. <br /> s <br /> 1 <br /> FEE0�; <br /> LESS } } t <br /> PRORATION # <br /> PLUS <br /> PENALTY <br /> OTHER 1 i <br /> OTHER �l <br /> k � -�"{Q�c�3 ��11 cf l � Delivered <br /> 4 Issuance Date Mailed <br /> Receipt No Permit No.L <br /> eceived by Date 1661E HAZELTON AVE.,P.O.Bvx 20119 .STOCKTON,CA 95205 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMITlSERYICES <br />