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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TneApP1lG211110n. <br /> -' APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 'D ENVIRONMENTAL HEALTH PERMIT <br /> is LIQUID WASTE <br /> Application is r by ode t rry on usiness' -the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name ( Q) _ Q - Address <br /> Address I <br /> dd Owner w <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> 0. <br /> Contractor Licence No. c ' f <br /> 2 ck Title Date <br /> L Applica6ts,Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 ` Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> y <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD �� <br /> For July 1, June 30, 19 <br /> a <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> i <br /> 3. ❑ PERCOLATION TEST <br /> _ R.S.or R.C.E. No. � <br /> R.S.or.R.C.E. Name <br /> Test ovation Test Date/Time <br /> WI <br /> 4. 1 SANITATION PERMIT _ <br /> Job Address/Lo a on <br /> Own <br /> G' r./ Add ss <br /> M/bEPTIC TANK 11 CESSPOOL L CHING FIEL Q SEEPAGE PIT PACKAGE PLANT <br /> ,�, ❑ REPAIR ❑ OTHER <br /> F 6 PERMANENT ❑ TEMPORARY ► EW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �� r <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> 1` 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 /> t:,t" <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;,and rules and regulations of the San Joaquin Local Health District. <br /> k' APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Receiv AEMITBy uly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> —BASE......... EXPLANATION DATE - DATE REMITTED AMOUNT- <br /> . <br /> FEE , Lfr' <br /> r. LESS <br /> PRORATION <br /> ` PLUS <br /> fl PENALTY <br /> OTHER / <br /> OTHER - <br /> Received by Date T Re.eipl No. ermil No. ssuance Date Mailed ;DelCKTO r <br /> ENYIRO MENTAL <br /> HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200 <br /> APPLICANT—RETURN ALL COPIES TO: 0I(TOrJ��9520`,1 <br />