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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION r <br /> y (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> LIQUID WASTE OD <br /> Applic ' n is heFeby made t carry on business in the'uris fictional area of the an Joa in Local Health Distr' t <br /> ,,Busines ame (DBA + Add ess <br /> z Owner Address , <br /> a <br /> j Firm Partners, Addresses and Telephone Nu ers <br /> aBusiness Telephone No. �'Q 10� Emergency Telephone Na. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable C gory(1-7)and Fill irghe 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 /> Serial No, CAL. License No. 1. CAL. License Renewal No. t <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address l <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.G.E. Name # R.S. or R.C.E. No. <br /> Test Lo tion Test Date/Time r` <br /> 4. SANITATION PE l i <br /> Job Add r /Lo tion r <br /> Owner — _ Addres,,s/ i r-r <br /> SEPTIC TANK 1:1 ,,,LE <br /> CESSPOOL ACHING FIELD a SEEPAGE PIT ❑ PACKAGF PLANT <br /> P"PERMANENT ❑ TEMPORARY I STEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 # 4.{t <br /> Type Construction r Disposal Site <br /> ri <br /> No. of Units Equipment Storage/Cleaning Location(s)' <br /> 6. ❑ PACKAGE TREATMENT PLANT FortAly 1, -June 30, 19 ti ff l <br /> Operator Name Where`Certif_ied ' <br /> Plant Location <br /> Plant Capacity No. Units Served It 7;, <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 /> r � <br /> 4t <br /> I hereby certify'that'i"have prepared this application and that the wor will be done in accordance with San Joaquin County <br /> ordinances, state laws and rules and gu tions of the San Joaquin Local R Ith District. <br /> APPLICANT'S SIGNATURE X <br /> �0 <br /> FOR DEPARTMENTfi� <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH nuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING R ITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE jf <br /> �S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY IA <br /> OTHER <br /> OTHER <br /> ' <br /> ReceivedbyDate Receipt No. Permit No. Issuance Date Mailed elivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMITISERWCES, 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKY N,CA 9 01 <br /> "y . <br />