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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) 1� <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE .: <br /> LIQUID WASTE <br /> Application ' eb de t c rry on busi. ss/ the jurisdictional area of the San Joaquin Local.We ric �; H <br /> yBusiness Name (DBA) Address <br /> cOwnerAddress <br /> J Firm Partne s, Addresses and Tele hone Num r <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Require Intormalion ? <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 ,f I ; <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4.,X SANITATION PERMIT f ; <br /> Job Addr / ocatio <br /> caner Addie <br /> SEPTIC TANK ❑ CE5'SPOOL LEACHING FIELD SEEPAGE PIT PAC AGE PLANT <br /> PERMANENT ❑ TEMPORARY_ NEW ❑ 1 s <br /> _ W REPAIR OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For'July'• 1'4 June 3.0„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 i <br /> Operator Name ` �` f Wf1 re Certified <br /> Plant Location # '` <br /> Plant Capacity No. Units Served *- t <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 { — <br /> SIZE: <br /> C3 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 prepared this application and that the work will be done.in accordance with San Joaquin County <br /> ordinances, state laws, u ngrgulatiollM theSanJoaquin Locd ealth District. ” <br /> t <br /> APPLICANT'S SIGNATURE X h� <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 : <br /> REMIT a <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT i <br /> FEE W - - .✓!, � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuanc Date7 Mailed v e-Mt 1. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONLAVE.,P.O.Boz'2001 -95201---7- <br /> .s , <br />