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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION' <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica n is hereby m de to car on bus'ne s in t e jurisdictional area of th San J quin Local <br /> Healt Disthc.. . <br /> rn Busine ame (DBA <br /> i Address rel 1 <br /> i Owne Address <br /> Firm Partners, Addresses and Tel hon Num mvs <br /> r� <br /> a d S Emergency Telephone <br /> a. Business Telephone No. <br /> Contractor Licence N. <br /> LApplicants Name (Print), - �Ti-tle. � Date <br /> Please check Applicable _egory (1-7)and Fill n the Required Information. <br /> 1. C) PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,' .`-`June 309 -^ = '= Disposal Sites... i <br /> Description(Make/Yr.,,Color)IK'� <br /> CAL. License Renewal No. 4 <br /> Serial No. •. - CAL. License No. � - <br /> +y_Capacity'" Gal.,Weights Z3 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 V <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> - R.S. or R.G.E. No. z <br /> Test,�,L,�ocation I V 4 Test Date/Time <br /> IN <br /> 4. SANITATION PE MIT _ <br /> Job Add r s/L *tion <br /> O_w/ner Add�ess� <br /> l� SEPTIC TANK Czz <br /> ESSPOOL::;;,�.4 BLEACHING FIELD {®SEEPAGE P{7 PACKAGE PLANT r�r <br /> VP•ERMANENT'' ❑ TEMPORARY' ❑ NEW` +� _ ❑' REP.AIR <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19-- _ k <br /> Type Construction i rDisposal SZ <br /> — <br /> No. ui men tStora a/Cleanin Location(s} <br /> No. of Units - I _ _4 P � 9 9 <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, <br /> Operator Name _ .Where Certified <br /> I I 41\ <br /> Plant Location 1 4 <br /> k Plant Capacity'f E No. Units Served <br /> 7. ❑ LAUNDRY For;July 1, -June 30, 19 <br /> SIZE: ❑ Less Than�1,000 SgTFt., ❑ More Than 1,000 Sq. Ft. = <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owneroriicensedageftt'ssgrfalurecertI ie9thefo!1owin9;1certifyltd`:,Iqtheperfortnanceoftheworkforwhich this permit is issued,lshall not employ any pert^n <br /> in such manner a5'to beconla suibjeut,, of Ca!i#Lrrii«.' i <br /> Contraetor'e Hiring or sub-c"trictirrg 949nsturo ca rtifif;;: 1to ioliowin l CsrtffY Eh Ft in�the_peFfoLtt�arlee.of.the-wtirk.fdr whi6E1 t4tis hermit is issued,I shad <br /> employ yetsons f 04ject tn.workmari s compensation laws of California." <br /> I hereby certify that I have prepared this application'and that the work will be done in accordance with San Joaquin County <br /> £�or'dinances,`state laws, and rules and r ulat'Ons of the San Joaquin Local Health District. <br /> , y <br /> APPLICANT'S SIGNATURE X ` <br /> 4 <br /> 1 FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EIEACH E3 January 1 & eceived By January 31 July 1 d Received By July 31 <br /> jj REMIT <br /> j BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> f (ii DATE DATE REMITTED AMOUN <br /> tv <br /> FEE 4 <br /> LESS <br /> f PRORATION x' 3 ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No <br /> issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES' 1601 E.HAZELTON AVE.,P.D.Box 2009 5 OCKTON,CA 95201 <br /> - � <br />