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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ Ile <br /> T APPLICATION <br /> � v�= (For Non-Transferableevo <br /> , Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL <br /> PERMIT <br /> G}� LIQUID WASTE <br /> Appf ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Loca Health District <br /> Business Name (DBA) i Address <br /> '- <br /> z Owner Address �. . <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. Emergency Telephone No' <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) j <br /> For July 1, M June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) " <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 Y, June 30,19 <br /> No. of Vehicles 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 ocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Locati <br /> Hers 5 �f15 r s <br /> VLEACHINGSEPTIC TANK ❑ CESSPOOL FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT %[3 TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER41 <br /> 5. ❑ CHEMICAL TOILETS 'For-July 1, -June 30, 19 <br /> Type Construction I Disposal Site <br /> No.-of-Units_ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMtNT-PLAfVF `For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> ' <br /> Plant Capacity No. Units Served <br /> �. '; <br /> 7. ❑ LAUNDRY For July 1 -June 30,'19 -: <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chepicals Used/Arriount/Mo. <br /> y i <br /> HOMO owner or:icensea agent`s sigm-.0re certifies the hill wing:"I certify that iR the pErfn: <br />