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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 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> or Business Name(DBA) Address <br /> Owner Address <br /> n Firm Partners, Addresses and Telephone Numbers <br /> 3. Business Telephone No.. Emergency Telephone No. <br /> 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 i <br /> Description(Make/Yr.,Color) ; <br /> Serial No. CAL.License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights&Measures No. a °� <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 i <br /> 3.,'0 PERCOLATION TEST <br /> R.•S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time t <br /> 4..❑ SANITATION PERMIT Ij <br /> Job Address/Location l I <br /> Owner ` <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL. ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT) ! <br /> ❑ PERMANENT ❑ TEMPORARY-'- ❑ NEW ❑ REPAIR ❑ OTNER ) <br /> 5. ❑ CHEMICAL TOILETS For July.1,-June 30, 19 <br /> Type Construction ' ' � <br /> Disposal Site '► <br /> No. of Units _ Equipment Storage/Cleaning Location(s) ) _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For.luly 1,-June 30, 19 r <br /> Operator Name o Where,Certified <br /> Plant Location <br /> Plant Capacity No. Units Served 3 __ 00-*Ow <br /> 7. ❑ <br /> LAUNDRY.;For July 1,-`June:30, 19 - i x <br /> SIZE: ❑ Less Than 1,000 Sq. Ft e a More Than 1,000 Sq. Ft, r '-'� 6 ` <br /> ❑ DRY /CLEANING,Chemicals Used/Amount/Mso.• i r' <br /> I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin County I <br /> ordinances,state laws,and rules and regulations of the-San Joaquinocal Health District. ; <br /> APPLICANT'S SIGNATUREX ` <br /> FOR DEPARTMENT USE ONLY <br /> • Fee IS DUO: ❑ ANNUALLY ❑PER UNIT' ❑ PER SITE ❑ EACH ❑ January t &Received By January 31. ❑July 1&Received By July 31 <br /> 1 r: 111 <br /> BASE EXPLANATION BILLING `REMITTANCE s REMIT <br /> DATE 'a DATE REMITTED AMOUNT DUE CHECKED <br /> - �. AMOUNT <br /> FEE. <br /> LESS <br /> PRORATION <br /> PLUS N } <br /> PENALTY <br /> i�. ► 'is <br /> OTHER 1 <br /> t 4. <br /> OTHER <br /> Received by Date _ Receipt No. - Permit No. - Issuance pate Mailed Delivered <br /> APPLICANT—RE1],1RN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ;1601 E.HAZELTON AVE.,P.O.Bon 2009 STOCICTON,CA 95301 <br /> i y <br />