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a r Applications Will Be Processed When Submitted Properly Completed. Be Sure 7o Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio� od <br /> is hereb e to carry on�siness in the jurisdictional area of the San Joaquin Local Health District � -Z <br /> NBusiness Name (DBA) a � Address <br /> z Owner Address <br /> t <br /> Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. —?C0Emergency Telephone No. <br /> Contractor Licence No. I �a <br /> L Applicants Name (Print) �{ Title 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) I <br /> Serial No. CAL, License No. CAL, Licc,se 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 i <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 /> i <br /> Test Location Test Date/Time <br /> 4. g SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> �❑�( SEPTIC TA K ❑ CESSPOOL LEACHING FIELD � SEEPAGE PIT ❑ PACKAGE PLANT <br /> c><+`�PERMANENT ❑ TEMPORARY ❑ NEW REPAIR 13 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 1 <br /> Where Certified <br /> Operator Name <br /> Plant Location 16 <br /> Plant Capacity No. Units Served <br /> f 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> f 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, ay rules and egulapier of an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Ta <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT l0 PER SITE '❑ EACH ❑ January 1 8 He et7 ti January 31 ❑ July 1 &ReceivedREMITuIy 31 <br /> BASE EXPLANATION BILLING, R4WfANGE AMOUNT DUE CHECKED <br /> DATE DATE REMITT DQ� < AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> ' PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d S 1 <br /> I Issuance Date Mailed .De"v ed <br /> Received by Date <br /> Receipt N. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON,CA 95201 i <br />