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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 t <br /> C.. <br /> }� LIQUID WASTE <br /> Applicatio hereby ma to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) "` ��� �� S�II�l�s�`L— Address 105 1 <br /> aOwner i_(j C Address <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> I, 0.a Business Telephone No. '��S`^ �G Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) r Title Date _' , <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 /> i Serial No. <br /> 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 /> F <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. C <br /> Test Location Test Date/Time <br /> 4. W SANITATION PERMIT <br /> f Job Address/Location �a <br /> Owner At—if7l"IVAddress 41-11 <br /> IX SEPTIC TANK ❑ CESSPOOL IWLEACHINGFIELD 'SEEPAGE PIT ❑ PACKAGE PLANT U <br /> IX PERMANENT ❑ TEMPORARY 5rNEW ❑ 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 /> t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 1 ordinances, state laws, ules and re ulations f the San Joaquin Local Health District. <br /> s <br /> APPLICANT'S SIGNATURE X <br /> lI FOR DEPARTMENT USE ONLY <br /> F Fee IS Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Cl January t&Received By January 31 ❑ July 1 &Received By July 31 <br /> F REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - [y DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> v <br /> # PLUS <br /> PENALTY <br /> r OTHER <br /> OTHER <br /> 1 Received by Date Receipt-No. Permit No. I suanc Date Mailed eliver d <br /> l - - APPLICANT—RETURN ALL COP1E5 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Bol 2009 5TOC ON, A 95201 <br />