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F „ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION s <br /> (For Non-Transferable, Revocable, and'Suspendable) t <br /> ENVIRONMENTAL HEALTH .PERMIT SEPTAGF <br /> 0 <br /> LIQUID WASTE as <br /> App]icati Is herebya to carry n busib�`'�sl 0Aness in the jurisdictional area of the San Joaquin Loc Health District� <br /> OF Business Name (DBA) L( $ b F _Address r,1P,f <br /> aOwner Address <br /> J Firm Partners, Addresses anp one Numbers j <br /> m Business Telephone No. d T I ���. -..- Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) Title Date <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 /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,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. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT ! N b <br /> Job Address/ ocatio _ <br /> Owner Address <br /> ❑ S TANK SSPOOL ACHING FIELD Z'TEEPAGE PIT ❑ PACKAGE PLANT ' <br /> 99"PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 09; <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <br /> Type Construction Disposal Site <br /> No. of Units 1 Equipment Storage/Cleaning Location(s) - ~ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, —June 30, 19 F ' <br /> Operator Name Where Certified} ; <br /> Plant Location <br /> Plant Capacity -- No. Units Served. « -� 9- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. J <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ' t <br /> I hereby certify that I have prep this application and t e work will be done in accordance with San Joaquin County d <br /> ordinances, state laws, and ruja6wrd regulat' ns of uin I District. <br /> APP'LICANT'S SIGNAT <br /> y• _ FOR DEPARTMENT USE ONLY <br /> " Fee 7s Due: ❑v'ANNOALLY ❑ PER UNITS PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> t. '- • - BILLING REMITTANCE $ <br /> BASE ILXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> id AMOUNT <br /> - <br /> FEE T.�•; �r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -•.,. - ;.. Date-_ Receipt No. Permit No. Issuance Date ,Mailed Dellve d <br /> . v <br /> APPLICANT-RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E:HAZELTON AVE.;P.O.Box: STOC TON,CA 95201 - `7 <br />