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rrrLIL.N 1 ILJI11 <br /> ' (F -Non-Transferable,Revocable,and Suspendabte) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT tea/ <br /> LIQUID WASTE <br /> Applicali hereby ado to carry on busine in the jurisdictional area of tan Joe in Local Health Distric <br /> F Business Name (DBA) }1C I Ad ress O t, - D <br /> iOwners Addre <br /> Firm Partners, Addresses and Telephone Numbers -_4c2s 1 <br /> Business Telephone No. Emergency Telephone No. 3.. ' 1 <br /> Contractor Licence No. - <br /> - .: 4 <br /> L Applicants Name (Print) M _ _ _..Title Oata Q - - <br /> Please cheek Applluble Category (1-7)and FIII In to Required Information a ' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) N <br /> For July i,- June 30, 19 Disposal Sites 1 <br /> Description(Make/Yr., -- <br /> Serial No. CAL.License No. _CAL.License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <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 _ 1 <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> 4 - Location - - Test Date/Time n <br /> . SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> -SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ <br /> Operator Name Where Certified <br /> Plant Location ----_- — ` <br /> Plant Capacity - - No. Units Served --�- - _ IV/l\ <br /> 7. C1 LAUNDRY FOFsJuly 1, -June 30, 19 - - <br /> SIZE. ❑ Less Than 1,000 Sq. Fl ❑ More Than 1.000 Sq Ft <br /> ❑ DRY CLEANING, 41hemicals Used/Amou t/Mo <br /> Ir.inch m <br /> ISuChmanner llraratedaonnYss eno r sri;l t`!0 rel+nw tl6 Ir i+ �:a r••� <br /> anner as to h».ome 5uhjecl to rvrkm_.c'. e.^.�aLCn laws n'(a•imr:s - ,.n,T•;`Oq "L Mork ta'tvhich this permit is issucM shall not employ any perr <br /> Ccntrector'E hiring or subcont seting .,iM1at e0 certifies the fcileviing' -'I E I':Y il:at i.t the"rv9(�(md,^..p C:,:e w0'6 for which! - -r ;5 iSSUCd,I Shall <br /> C:nplcy persons sut,jecl to workman s Lor). s .aws of Caliternia: <br /> ID <br /> I hereby certify that 1 have prepared this 9pplication and that the work will be done in accordance with San Joaquin County 'A <br /> ordinances, state laws, rules antl r u do frthe San Joaquin Local Health District. <br /> 4PPLICANTS SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January at ❑ July t a Received By July at <br /> BASE EXPLANATION BILLING REMITTANCE f REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - - '-- -- -- AMOUNT <br /> FEE L — — J/ <br /> LESS ©� <br /> __. _____ __ - <br /> PRORATION - <br /> PLUSPENALTY <br /> OTHER J it •T� T <br /> OTHER <br /> ilecerved sy owe . Receipt No. --_ eo�-�_--..—.ssuance�-" �' , liver II{ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.a.3009 STOCKTON,CA WNI <br />