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f n � Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r„ (For Non-Transferable, Revocable, and Suspendable) SEPTAGE ! <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carg on business in the jurisdictional area of the San Joaquin Local Health trict <br /> FBusiness Name (D A) <br /> Address <br /> z4 Owner <br /> Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. C Emergency Telephone No. <br /> Contractor Licence No. ��� Date - 7 <br /> Applicants Name(Print) _ Title <br /> Please check Applicable Category (1-7)an�_4 �theReq�ltormaiion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr:, Color) t- <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address. ' <br /> 2. 0 PUMPER YARD <br /> For July 1, June 30, 19 _ _ N <br /> No.of Vehicles Stored N <br /> No. of Chemical Toilets Stored �- L6--6 -14, <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E!NO- C <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Lation r <br /> 4. L� SANITATION PERMIT <br /> �2, <br /> �2 s'Job Address/Location Ow,r E r ddress <br /> �� 0 COOL L CHING FIELD IT 1] PACKAGE PLANT <br /> ASEPTIC TANK ❑ OTHER <br /> 11 �" PERMANENT ❑ TEMPORARY NEW ❑ REPAIR <br /> 5. 0 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site ' <br /> Type Construction * s " <br /> f No. of Units Equipment Storage/Cleaning Location(s) <br /> S 6. 0 PACKAGE TREATMENT PLANT For July 01,;-June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served . <br /> Plant Capacity _ <br /> 7. 1:1 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq, Ft., 0 More Than 1,000 Sq. Ft. <br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules d regulations of the San Joaquin Local Health District. <br /> t APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE El EACH ❑ January 1 &Received By January 31 © July 1 &ReceiveRENylTuly 31 <br /> l BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS '�" <br /> PRORATION <br /> PLUS <br /> f PENALTY . <br /> i <br /> OTHER - <br /> 7 Z� r <br /> ssuance Date Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSERVICES - 1601 E.HAZELTON AVE,,P.Q'Box 2009SC � <br />