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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign 1neAppucauUrr. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) <br /> ilf�_g SOS$ �.[� . Address <br /> Address <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � % Emergency Telephone No. - <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title QST Date <br /> Please check Applicable Category(1-7) and Fill In-the_Regdlred Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 0 <br /> CAL. License Renewal No. <br /> Serial No. CAL, License No. <br /> Capacity Gal., Weights &Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 '\l <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 Date/Time <br /> Test Location ' <br /> 4. -SANITATION PERMIT 6 <br /> Job Address/Lo tion <br /> Owner ' Address N. <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW La REPAIR ❑ OTHER A <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ule5 an regula ns of an Joaquin Lacal Health District. x <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &ReceivedREMITuly 31 <br /> RASE EXPLANATI N BILLING REMITT CE $ AMOUNT DUE CHECKED <br /> DATE D REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> q <br /> Received by - Date Receipt No. Permit No. Is uance Date Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI$ERVICES 1601 E.HAZELTON AVE.,P.O.Box 20{19 STOC ON,CA 209 <br />