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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> or Non-Transferable,Revocable, and Suspendabltl <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> y` LIQUID WASTE <br /> Application eregy made/}pV�� ry O 4siness in the jurisdictional area of the Sa Joe in cal Heath Dis/Vict J <br /> 3usiness Name (DBA)�/t /fir N 01-9. Address S� a- et1Q/1'1 rN�^ rr <br /> -Owner Srp- � Address <br /> Y Firm Partners, Addresses and T gphone umbers <br /> 3usiness Telephone No. "- ?'C Emergency Telephone No. <br /> rOontractor Licence No.?.7 X _ 7 3 T r <br /> .._/./4t Title (SL(A11JP2 nate <br /> ,, <br /> Applicants Name (Print) r !=�-��" ' <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 Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD C <br /> For July 1, June 30, 19 C <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 3-ocation Test Date/Time <br /> 9. SANITATION PER IZ gOD ; I O a, j /tJ T-N <br /> r,Job Address/i0 tions G Z �l /0 C <br /> O mer Address <br /> SEPTIC TANK ❑ CESSPOOL eeeiiir LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> JPERMANENT ❑ TEMPORARY 4�NEW ❑ REPAIR ❑ OTHER <br /> `S. ❑ 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 herebycertify that I have yrepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, <br /> apd.Iul and regulations f the San Local Health District. <br /> (/fy <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> NOW ---�/� <br /> \b V <br />