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- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT j <br /> LIQUID WASTE <br /> Application i ereby mad to car on business in the jurisdictional area of the San Joaquin Local Healt D'strict 4 <br /> yBusiness Name (DBA) Address <br /> aOwner : Address Y <br /> Firm Partners, Addresses and Telephgne Numbers <br /> CL Business Telephone No. ., Emergency Telephone No. <br /> 1 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) <br /> 4. <br /> For July 1, -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 /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> 1 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 Date/Time <br /> I 4, IgSANITATION PERMIT 7 /-� <br /> j Job Addres, Location <br /> Owner _ <br /> [J- Address �al a�i� .._ <br /> r ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> [ XPERMANENT ❑ TEMPORARY NEW 11REPAIR ❑ OTHER <br /> !! 5. 13 CHEMICAL jTOILETS For July 1, -June 3019 t � <br /> Type Constructions Disposal Site } <br /> No. of Units Equipment-.Storage/Cleaning Location(s) ) �i <br /> ii - <br /> k 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> [ Operator Name I WhereCertified <br /> Plant Location C <br /> Plant Capacity � -- 'r ., "4 � No. Units Served <br /> a <br /> 7. 11 LAUNDRY 1----June-30,-19--- -*—* -� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000,Sq. FL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> P � 1 <br /> I hereby certify that,I repa red this application and that the work will be done in accordance with San Joaquin County r <br /> l ordinances,g Vs, a,;,a and regulations the S n Joaquin Local Health District. ` <br /> APPLICANT'S SIGNATURE X ` <br /> r <br /> s4 <br /> f FOR DEPARTMENT USE ONLY , ,t <br /> Feels Due: D ANNUALLY ❑ PER UNIT PER SITE ❑ EA ElJanuary 1 &Received By January 31 ElJu#y 1 &Received By July 31 <br /> yyON t REMIT <br /> BASE EXPLANATI <br /> r BILLING ;r.REMITTANCE AMOUNT DUE CHECKED' <br /> I DATE f DATE REMITTED <br /> I AMOUNTr <br /> FEE <br /> LESS <br /> PRORATION. <br /> PLUS <br /> PENALTY .� .... - <br /> OTHER j 7 ' <br /> OTHER <br /> x - 6 0� _ <br /> Received by Date Receipt No. Permit No. a Issu nce Da[ Mailed a iv ed <br /> 4 <br /> APPLICANT—RETURN ALL COPIES TO: � ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST KION, 9201 <br />