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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppllcauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ma o carry o usin ss in the jurisdictional area of the San Joaquin Local Health District ^� <br /> N[Business Name (DBA)�!� - 7r �` Address �� <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. 5KAEmergency Telephone No. <br /> Contractor Licence No. <br /> e, d <br /> Applicants Name (Print) � w LGc Title Date y <br /> I <br /> Please check Applicable Category (1-7)and Fill in the Required Information t, <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 /> Capacit Gal., Weights & Measures No. <br /> Y Y <br /> t ' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD :) <br /> For July 1, June 30, 19 )'-` <br /> No. of Vehicles Stored e <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST-. <br /> R.S. or R.C:E. Name R.S. or R.C.E. No. F <br /> a <br /> Test Location Test Date/Time 1 <br /> 4. ❑ SANITATION PERMIT <br /> r Job Address/Location <br /> own ' � G F11Address <br /> M SEPTIC TANK ❑ CESSPOOL ACHINIELD SEEPAGE PIT 11PACKAGE PLANT ; <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. © CHEMICAL TOILETS For July 1,-June 30, 19 #p t <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> r I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1 June 30, 19 4 — " <br /> Operator Name , Where Certified <br /> Plant Location { <br /> Plant Capacity x No. Units Served a <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Than l,000S_g l=t:" <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> y I <br /> .1 hereby certify that 1-have-prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and ul� ions f e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X p k <br /> � � t <br /> FOR DEPARTMENT USE ONLY c <br /> f Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Received By January 31 July 1 8 Received By July 31 <br /> t fF REMIT <br /> P - BASE EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> • DATE DATE REMITTED AMOUNT <br /> FEE �'�7—,LESSPRORATIONPLUSYPENALTY OT1iER ".' F. y `* N 7 T <br /> OTHER ? <br /> Ls <br /> 'Received by Date Receipt No. Permit No. <br /> uance ate Mailed Delivered - <br /> APPLICANT-RETURN ALL COPIES TO:' .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O,Bo■2009 -STOCI(TON,CA 952 <br />