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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApprncalion. <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 bus"', s in th ju isdictional area of the San Joaquin Local Health District l <br /> yBusiness Name (DBA) Address— <br /> i Owner �— �— Address <br /> Q <br /> Firm Partners, Addresses an�Teharte Nl,tm ers <br /> d S Emergency Telephone No. <br /> a Business Telephone No. <br /> 4K Contractor Licence No. r <br /> L Applicants Name (Print). � E, A� L� Title C 0Date q <br /> Please check Applicable Category (1-7) and Fill In the Required Information lr <br /> r <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 Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location Lr <br /> OwnerAddressIELD EEPAGE PIT F—SEPTIC:TANK�101ESSPOOL LEACHING F ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY © NEW ` ;�EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site '`. <br /> No. of Units Equipment Storage/Cleaning Loc <br /> aiion(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 ~ <br /> Where Certified <br /> Operator Name <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 h ve prepared this plication av that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules and regulat ns f t e n Jo uin Local Health District. <br /> APPLICANT'S SIGNAT } <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER j) " <br /> OTHER <br /> 1 ,S71 <br /> Reciedtw­ Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCi(TON;CA 95201 <br />