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A-piiclp ations Will Be Processed When Submitted Properly Completed. Be SureTo Sign IneAppnt;42t, <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application_i�hereby mad to carry on business in the jurisdictional area of the San Joaquin Local Health�Dissttrict <br /> ll Address <br /> Business Name (DBA) <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Nu ber�s <br /> a ' <br /> j <br /> ,� S - �L - ! Emergency Telephone No. <br /> aBusiness Telephone No. _ <br /> Contractor Licence No.�� Date I <br /> Title <br /> Applicants Name (Print) <br /> Please check Applicable Category(1-7)and Fill In the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 _ Disposal Sites <br /> Description(Make/Yr., Color) CAL.-License Renewal No. <br /> Serial No. CAL. License No. ' _ <br /> Capacity Gal.,Weights R 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 TESTI <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> .Test Date/Time I <br /> Test Location f I <br /> 4. ❑ SANITATION PERMIT 4C 7 <br /> Job Address/Location 4 V <br /> t Address %J , <br /> Owner C1 PACKAGE PLANT <br /> M1 EPTIC TANK 13 CESSPOOL <br /> j LEACHING FIELD ❑ SEEPAGE PIT :I ❑ OTHER <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW 11 REPAIR -' t <br /> 5. © CHEMICAL TOILETS For July 1, -June 30, 19 + V. <br /> Disposal Site <br /> Type Construction y f <br /> Location(s) <br /> anin <br /> e/Cle , <br /> No. of Units <br /> Equipment Storage/Cleaning 9 � = k <br /> r g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name 4— <br /> Plant Location ` �T <br />!! No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 F 1 <br /> SIZE: ❑ Less Than 1,000'Sg��t., 0 More Than 1,000 Sq. Ft. <br /> El DRY CLEANING,Chemicals Used/Amour Mo. <br /> I'hereby certify that 1:have prepared this application and that the work will be done in accordance with San Joaquin County <br /> rregulations of the San Joaquin Local Health District. <br /> ordinances, state laws, and rules ar t <br /> APPLICANT'S SIGNATURE X <br /> s, <br /> FOR DEPARTMENT USE ONLY By <br /> Fee IS Due: ❑_ANNUALLY- . ❑ PER UNIT 'aPFR SIT�. E.❑ EACH —❑ January 1 &Received ByJanuary 31 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> i ' XPLANATION BILLING - REMITTANCE $ �r AMOUNT DUE CHECKED <br /> BASE E <br /> ' DATE DATE REMITTED AMOUNT <br /> FEE J -- - - <br /> LESS ~ <br /> PRORATION <br /> �- PLUS - -.'PO <br /> f PENALTY .A e r <br /> s <br /> OTHER <br /> OTHER _��.-•--- - -._•-. -- _ - _ - _ <br /> Permit No. Issuance ate Mailed' Deliv red <br /> Date Receipt No. - _ <br /> ' Received by - 1601 E.HAZELTON AVE.,P:O.Boz 2009 ST(:) KION, A 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENYIAONMENTAL HEALTH PERMITlSERYICES <br />