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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION " <br /> l� <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ) <br /> t LIQUID WASTE r <br />? Applicatio��l`s her a e to c n slness in the jurisdictional area of theP o&n Local Health D rict <br />�O Business N (DBA) `�^C- Addre r �� f f <br /> i Owner_ �ec.Ae F Address �/ <br /> Firm Partners, Addresses and T lephone Numbers <br /> Business Telephone No. Emergency Telephone No. Arc- <br /> Contractor Licence No. 7 <br /> Applicants Name (Print) Title O AAw Date Z-/7. 7 S <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. '' t <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.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time l <br /> 4. 'SANITATION PERMIT �� <br /> Job Addre Loca ' n <br /> c� .�o <br /> Co Address 3 �; <br /> Owner - <br /> ❑ PACKAGE PLANT <br /> `a SEPTIC TANK ❑ CESSPOOL ,,�� LEACHING FIELDEPAGE PIT <br /> �ERMANENT ❑ TEMPORARY IE -KE-W ❑ 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 <br /> Operator Name Where Certified <br /> Plant Location u <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 /> y <br /> I hereby certify that I have pre ed this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and Ind re ns the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> 3 <br /> j Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1'&Received By I 31 <br /> � REM17 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED ' <br /> BASE EXPLANATION DATE DATE REMITTED - ` <br /> AMOUNT <br /> FEE J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —1083 7 <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed D rvered <br /> APPL1 T�RETUR� L COPIES IRON�M�/ALH LTH PERMITI ICES _ �a601 ELT .,P.o Q S 4C1 ICA 95201 <br />