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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ( 1 LIQUID WASTE <br /> Application is hereby ruade tor on busi ss in th risdictional area of t1ja4an Joaquin Locgl Heal (strict <br /> OF �.- _� L L ( 1 Address <br /> Business Name (DBA) <br /> a Owner _���- )Ai Address <br /> Firm Partners, Addresses al�i I pone N�mI ers <br /> 0. Business Telephone No. J '�' Emergency Telephone No. <br /> __;1L <br /> Contractor Licence No. _ �( <br /> L Applicants Name (Print) ( V,_1 ���� i t-�, Title <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 V <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. 1 <br /> Capacity _- Gal.,Weights &Measures No. _ 9� <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD S <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. Name _ R.S.or R.C.E. No. <br /> Test Location Test Date/Time o <br /> 4. ❑ SANITATION PERI <br /> Job Ad Location <br /> Owner ( 1 � L��1 f{ Address <br /> El SEPTIC TANK 1J CESSIPOOA ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 0 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Morp Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby cetify'Ti ave prepared this application nd that the work will be done in accordance with San Joaquin County <br /> ordinances,st `aws an les and�Igulati San J quin Local Health District. <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 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ ' AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER U <br /> OTHER <br /> Received by I Date Receipt No., I Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 �STOCKT ,CA 95201 <br /> _ON <br />