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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati is ereby rry on Osiness ip the jurisdictional area of the San Joaquin Local Health ist <br /> ,„Business ame (D A Address <br /> zOwner: Address <br /> Firm Partn rs, Addresses and Telep one Numbers <br /> aBusiness Telephone No. �+ Emergency Telephone No. <br /> Contractor Licence No. to <br /> L Applicants Name (Print) Title ` Date <br /> Please check Applicable Category (1-7)and Fill in the4equired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites -- <br /> Description(Make/Yr., Color) <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, 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 <br /> 4. ,SANITATION PER <br /> Job Addres Ms 4,4 <br /> Owner Address <br /> ❑ SEP4 TANK ❑ CESSPOOL XLEACHING FIELDSEEPAGE PIT PACK E PLA <br /> 19 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. ❑ 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 r ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r and regul tions of the San Paquin 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 ❑ J By July 31 <br /> REM <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION MOUNT DUE CHECKED <br /> ` DATE DATE REMITTED AMOUNT <br /> FEE yZ V� ( `7 <br /> LESS <br /> PRORATION t <br /> PLUS #h 1 <br /> PENALTY <br /> OTHER (7 <br /> OTHER Vz <br /> 0-3 <br /> Received by Date Receipt No. Permit No. issuance Date Mailed WedAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br />