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t .. <br /> Applications Will Be Processed When Submitted Properly CompleteBe Sure o r <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE - <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is. eby.made t car on business in the juris 'ctional area of the S Joaquin Local Health trict <br /> F moi - Address <br /> yBusiness Name DBA) <br /> Address <br /> a Owner <br /> Firm Partners, Addresses and Telephone N mbers <br /> Z.a Business Telephone No. /"/? Emergency Telephone No. <br /> Contractor Licence No. Date 1.: <br /> r LApplicants Name (Print) Title <br /> Please check Applicable Category (1-7)and Fill in the Req red Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) , <br /> ` For July 1," _� `"'June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color)1 \ <br /> - <br /> -" s CALic:^se Renewal No. C <br /> Serial No. CAL License No. L � <br /> Gal., Weights & Measures No. <br /> Capacity �+ <br /> t 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. No. <br /> R.S. or R.C.E. Name <br /> Test L ation <br /> Test Date/Time r <br /> 4. SANITATION PERMIT e <br /> i Job Address/ tion <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ",LEACHING FIEL��D��ii IT ❑ PACKAGE PLANT ) <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW " '"r REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> Equipment Storage cation(s) <br /> /Cleaning Lo <br /> ;r <br /> No. of Units _ z <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 F <br /> Where Certified <br /> Operator Name r t ) ) <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> f 7. ❑ LAUNDRY For July 1, -June 30, 19 s. — ' ""'"'"'"► _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-, ❑ More Than 1,000 Sq. Ft. <br /> f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> { <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> egulations of the S n Joaquin Local Health District. <br /> ordinances, state laws, and rules an <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEByl July 31 <br /> EASE EXPLANATION 'BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE _ DATE REMITTED AMOUNT <br /> FEEj <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - 9-7 <br /> Date Receipt No. Permit No. Issuance Dae _ Mailed elivered <br /> Received by - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITfSE VICES 601 E.HAZELTONAYE.,,P.O.box 2009 STOCKY N,CA 95201_ <br /> - �--c�`1/!� <br />