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- Applications Will Be Processed When Submitted Properly Completed: Be Sure To Sign The Application. <br /> APPLICATION <br /> r � (Far Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicata is hereby made to car n business i the jurisdictional area oft San Joaquin Loc ealth Dist.ict , <br /> NBusiness Name Address <br /> 4 r Address <br /> z Owner <br /> K <br /> Firm Partners, Addresses and Telep a um rs <br /> Q. Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. 1 � <br /> Title Date <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) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gat., 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 <br /> R.S.or R.C.E. No. ° <br /> R.S. or R.C.E. Name - <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT �f <br /> Job Addres cation ` 0' [� <br /> Owner r Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL R LEACHING FIELD CR SEEPAGE PIT ❑ PACKAGE PLANT [/ <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> t 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units - Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> 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 /> l ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I hereby certify that I have prepthis application hat the work will be done in accordance with San Joaquin County <br /> '00ordinances, state laws, and nd re lations an Jo quin Local Health District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> „FEE <br /> LESS <br /> 1 PRORATION <br /> t PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Y <br /> :79 <br /> 3 35 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deliv ed -• <br /> '--APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - a-1601 E.HAZELTON AVE.,P.O.Box 2Rf19 STOC TDN CA 95217440 _ <br />