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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> s <br /> Application is hereby a to carry busines in the jurisdictional area of the Say, aqui Local Health District <br /> Address 1 <br /> rn Business e (DBA) <br /> Address <br /> a Owner <br /> 0 Firm Partners, Addresses and Telephone Numbers I <br /> &, Emergency Telephone No. j --4. <br /> aBusiness Telephone No. a <br /> Contractor Licence No. 4� Date �� <br /> Applicants Name (Print) <br /> tG[G. Title <br /> Please check Appilcable Category (1-7) and Fill in the Required Information m <br /> 1. 13PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r `� <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. i <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 /> j No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. WSANITATION PERMITIt ' s <br /> Job Address/Location �' <br /> Owner _Address <br /> ❑,j PTIC TANK L3CESSPOOL LEACHING FIELD C-SEEPAGE PIT <br /> 13 PACKAGE PLANT II <br /> '+ f PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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 /> J <br /> i <br /> I hereby certify that 1 have prepare this applica' and that the work will be done in accordance with San Joaquin County <br /> 1 ordinances, state laws, and rul re la ion n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT it PER SITE ❑ EACH ❑ January 1 &Received By Jan ry 31 ❑ July 1 &ReceivedBy my 31 <br /> REMIBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> a PRORATION <br /> PLUS <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> 4 ..r_�,_..,. - <br /> Receipt No. Permit No. Issuance a[e Mailed DeliveT '? <br /> Received by c Date- <br /> APPLICANT—RETURN ALL COPIES TO. -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.a��00�� .�S�TICKT ,CA 6S1 <br />