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r Applications Will Be Processed When Submitted Properly Completed, Be Sure To SignTheApplicauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> Business N5r e (DBA) <br /> aOwner Address S' <br /> 1 Firm Partners, Addresses and Telephonq Numbers <br /> ' Emergency Telephone No. <br /> a Business Telephone No. <br /> s l' i' <br /> Contractor Licence No. Bate <br /> Title <br /> LApplicants Name (Print)������• ��1��- <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. 4 <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> t R.S. or R.C.E. Name <br /> Test L tion Test Date/Time4. SANITATION PERMIT /f s <br /> Job Address/Location �EP <br /> Owner Add s <br /> ❑ PA KAGE PLANT❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPA ❑ OTHER <br /> 1 ❑ PERMANENT ❑ TEMPORARY ❑ NEW Lrt'f;EPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, i9 <br /> Type Construction Disposal Site <br /> l <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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, Chemicals Used/Amount/Mo. <br /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> oaquin ocal ealth District. <br /> ordinances, state laws, and es and regulation of the Sa J <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY C3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS h� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No. Issuance Date Mailed Delivered- <br /> ) Received by D to - <br /> �� 4601 E.HAZELTON AVE.,P.O.Sax�2009 - STD ,CA 85201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ SA - 0 <br /> 13 <br />