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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 /> s Application is�hereby made to carry_ on business in the jurisdictional area of the.San Joaquin Local Health District <br /> ,n Business Name(DBA) .___. �I'r _ <br /> - - _Address - <br /> zOwner Address <br /> Firm Partners.Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> � <br /> Contractor Licence No. <br /> Applicants Name (Print) �r,L•r. :` ' -- + --- - - -. ---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 No. <br /> { Capacity Gai.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30. 19 <br /> ; <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. 0 SANITATION PERMIT <br /> Job Address/Location - ` r t = r �� ' r -`` f r <br /> 1 t s cv .. <br /> i Owner. i..: .Lf'< 3 i _ � Address <br /> F, <br /> [ISEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD .0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ,! PERMANENT ❑ TEMPORARY 13 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 34,'i9 <br /> Type Construction -Disposal_.Site, <br /> No.of Units Equipment Storage/leaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> i Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> I 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> k SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 5q. Ft. <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 Wles an r gulations of.tha Sap.Joaquin_Local Health District. <br /> - APPLICANTS SIGNATURE f" j { !- <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> F1 <br /> ' <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE .❑ EACH l] January 1 8 Received By January 31 ❑ July 1&Received By July 31 <br /> BILLING REMITTANCE ; REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> er.. BASE •--. ... AMOUNT <br /> FEE <br /> LESS <br /> . PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER .. <br /> l : <br /> OTHER 0. <br /> Received by K Date Receipt Na a �t Na Issuance Date rrtaded �Dellrered k .5 �Y r� rr K <br /> APPLICANT RETURN ALL CoP1F�sTCe ENVIROriWiENTA1 HEALTH PER1Y11TlSERYIt Sia c 3 „. 1t➢li rEgHAZELTO�t AYuE.PA Sox 290.4}��^STIkKTCM,CA 95 r , <br /> w. <br /> __ - A <br />