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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. , <br /> APPLICATION <br /> +� (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> �` ENVIRONMENTAL HEALTH PERMIT, <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address <br /> OF <br /> aOwneri/ ® Address <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> a Business Telephone No, �! � ' s Emergency Telephone No. - <br /> Contractor Licence No. <br /> L Applicants Name(Print) _r Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information. ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q t <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) �1 <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; M June 30, 19-. - -..- - - .. . T .. .7- <br /> .No.-of Vehicles.Stored <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job A dress/Locatibrl � e5 <br /> Owners �`� - Address <br /> , SEPTIC TANK 13 CESSPOOL' ,LEACHING FIELD ❑ SEEPAGE PIT <br /> C3PACKAGE PLANT ' <br /> ,PERMANENT C],TEMC1PORARY ❑rNEW z REPAIR 11 OTHER .`115._ ❑ CHEMICAL TOILETS For July 1, -Jurie'30,,-19'� ` <br /> Type Construction rrt -_ ,Disp al Site 7 <br /> No. of Units Equipment Storagd/Cleaning Location(s) F ` <br /> ❑ PACKAGE TREATMENT PLANT,. For July 1,-June 30, 19 <br /> Operator Name Where Certified - <br /> Plant Location4 ' <br /> Plant Capacity k No. Uni s ServBd`: <br /> 7. ❑ LAUNDRY For July 1, -June 30,19C> <br /> SIZE: ElLess Thant1,000 Sq. Ft., D More Than 1,000 Sq. Ft. f ) <br /> R <br /> ❑ DRY CLEANING,Chemicals-Uvsesd/Arnount/Mo. ' <br /> Ffameownarvrlic3nsedag :'ssig:a:c¢recrr:fi8yt`•q#fll gtirr "ic Y('t f<nt#urM1 ��rrianceeflheVaark for viNchthis permit isIssued,Ishall lot employ any perSDII <br /> IR Su;.h m2?1r+P.r 8;to beG{If118 SLIIJini'to WaI196na.,1 S CSI- n5a1f0^,1%!1'v`S Bi C.aii'ornin. <br /> Contractor's fs firing or sob-contracting sian=Itum- eerti.ien im gasiovuslta: "i certify that in the pertorinar}ce of the v9rrk for which this permit is issued,I steall <br /> employ persons subject to svor!:mans LUMPePsation last u(tiakfarnia." <br /> 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:r a and`regulat'oWof-th&S �anal Health District. <br /> APPLICANT'S SIGNATURE X� <br /> a <br /> $ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS,Due: ❑ ANNUALLY PER UNIT PER SITE 13 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> a <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> L OTHER <br /> i_ OTHER <br /> s s <br /> r ceived Date Receip N0. Permit No. Issuance Date Mailed Delivered <br /> 1 <br /> APPLICANT' RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BaX;2009 STOCKTON,GA 95201 <br />