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Applications Will Be Processed When Submitted Properly Completea. kie bure Ivolu- <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT h <br /> LIQUID WASTE t` <br /> Applicatio ' here made to carryon bu 'Hess in the jurisdictional area of the San Joaquin Li Health District 1 <br /> Addres i <br /> NBusiness Name ( ) Address <br /> aOwner <br /> J Firm Partners, Addresses and Tel hone Numbers Emergency Telephone No. <br /> • <br /> 116 <br /> Business Telephone No. <br /> IZ <br /> Contractor Licence No. Title �' Date <br /> Applicants Name (Print) <br /> C <br /> Please check Applicable Category (1-7)and Fill in the Requ' d Information b <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Lic-ynse Renewal No. { <br /> Serial No. GAL. License No. �1 <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> i 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I No. of Vehicles Stored <br /> r <br /> No. of Chemical Toilets Stored <br /> I� 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. j <br />+ R.S.or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> a a Zell. <br /> ) — � <br /> Job Address/Lo n Address <br /> Owner ❑ LEACHING FIELD C1 SEEPAGE PIT 13 PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESS OL ❑ REPAIR U1 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t Type Construction <br /> Disposal Site <br /> E, No. of Units Equipment Storage/Cleaning Location(s) <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30,�9More Than 1,000 Sq. Ft. <br /> SIZE; 1:1 Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, aDo les and reg 4 tions f the n Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> II <br /> FOR DEPARTMENT USE ONLY <br /> REM❑ ❑ PEH SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ IT July 1 &Received By July <br /> 31 <br /> Fee IS Due: ❑ ANNUALLY PER UNIT <br /> BILLING R MITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> S <br /> FEE r <br /> LESS <br /> PRORATION! <br /> PLUS <br /> ! PENALTY 'i <br /> OTHER <br /> i <br /> OTHER /1 <br /> U Permit No. 155 anc Dat Mailed eliver d <br /> Received 4y ate Receipt N <br /> APPLICANT—RETURN'ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1501 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,CA 4520 <br />