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Applications Will Be Processed When Submitted Properly Completed. tiebore Io algn %Iltl <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE �. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatlon Ise <br /> eby made to carry on usiness in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) Z 1"' Address <br /> aOwner ref LL �� -- — Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> J Contractor Licence No. <br /> Applicants Name (Print) 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 /> Serial No. CAL. License No. CAL. License Renewal Na. <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 /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT c <br /> Job Address/Location J .-- <br /> Owner 3- 7 Address <br /> P-SEPTIC TANK ❑ CESSPOOL P�EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ' <br /> O 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 /> Where Certified <br /> Operator Name <br /> Plant Location A <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <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 re ations the S oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> r <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 <br /> 1 BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> -.� -- DATE- . ,. DA REMITTED AMOUNT <br /> FEE _ <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER S <br /> OTHER- <br /> 3 R <br /> Received by Date Receipt No. Permit No. I 9 ance D to Mailed Delivered <br /> APPLICANT—RETURLL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sox 201�9 STOCK aN,CA 95201 <br /> � <br />