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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> y APPLICATION <br /> y- (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE C�1 <br /> Application is h y r71a to carry�busin n t e jurisdictional area of the7Sa8n �oaquin h,�jF ealth istrirt <br /> .n Business Na e ( BA) Addre s <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. -3 -5 Emergency Telephone No. <br /> Contractor Licence No. wn�r <br /> Applicants Name (Print) Title r 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 _j <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ft <br /> \' <br /> Test Location Test Date/Time Q <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> SEPTIC TANK ❑ CE SPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ,`I7F ' <br /> PERMANENT ❑ TEMPORARY X NEW ❑ REPAIR �OTHER �r <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 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> l <br /> hereby certify that I have prepared this application and that the wor ill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules reg a ions of the San Jo I c �ye th District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED - {' <br /> DATE DATE REMITTED ,(' .AMOUNT <br /> FEES Wim+ v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �f <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delive ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sox%OOS�6T0 TON,CA 95201 <br />