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Applications Will Be Processed When Submitted Properly Completed. BeSureTo blgn 1neHNpn�o;� • <br /> APPLICATION <br /> rt:• (For Non-Transferable, Revocable, and 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icati s he eby de to c ry on business in th jurisd'tional area of the San Joaquin Loc�alHealt i ri��� <br /> N Business Name (DBA µ �� Address <br /> ) - <br /> z Owner r Address <br /> a <br /> L) Firm Partners, Addresses and Telephone Numbers I <br /> 10 11, <br /> fl. Business Telephone No. Emergency Telephone No. <br /> -- <br /> Contractor Licence No. f Title Date <br /> Applicants Name (Print) <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 <br /> Description(Make/Yr., Color) <br /> CRL. License No. CAL. License Renewal No. � <br /> Serial No, <br /> Capacity Gal., Weights &Measures No. <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 R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> i Test Location Test Date/Time <br /> 4. SANITATION PERMIT 1y� <br /> Job Address L catio / ,SG <br /> 10( Address <br /> Owner <br /> ❑ SEPTIC TANK ❑ CESSPOOL $LLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT w <br /> �PERMANENT <br /> ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER a` <br /> i 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations} <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 hav ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, andr d regulations of th an Joaqui Local Health District. <br /> r <br /> APPLICANT'S SIGNATURE X <br /> r�3! <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY PE UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DAT REMITTED AMOUNT <br /> FEE J <br /> LESS <br /> PRORATION �11 <br /> PLUS I <br /> PENALTY , <br /> OTHER ti4 <br /> OTHER <br /> Receipt No. Permit No- I uance Date Mailed eliver <br /> Received by Date CA 95201 <br /> APPLICANT=RETURN ALL COPIES TO: ENYIRONMENTAL HEALTH PERMITlSERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON, <br />