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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 <br /> LIQUID WASTE � 1 <br /> Applicata n is her made to rry on siness in the jurisdictional area of the an Juin Local J lealt District 4 <br /> H eti <br /> Business N (DBA) Addre <br /> z Owner Address <br /> J Firm Partners, Addresses and T ephone Numbers <br /> a Business Telephone No. -25K Emergency Telephone No. <br /> � <br /> Contractor Licence No. n 1 <br /> a G(L Title A Date �' S 7� <br /> L Applicants Name (Print) v <br /> Please check Applicable Category (1-7)and Fill in the Required Information Q <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 `1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT ' 3 / <br /> Job Addre /Location [ �' `� <br /> Owner /Location <br /> Address ox <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD Z— SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 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 /> I hereby certify that I have prered this ap Acation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and regula f e San Joaquin Local Health District, <br /> 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 &Received By July 31 - <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED of AMOUNT <br /> FEE 4�5 <br /> LESS <br /> PRORATION <br /> Il PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2bb ? <br /> Received b Date Receipt No. Permit No I u e DateMailed Ii red <br /> vp P <br /> k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 29 ST TON A 9 O1 <br /> 08 <br />