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Applications Will Be Processed When Submitted Properly Completed..Be Sure To Sign The Application, <br /> I! n APPLICATION <br /> L . (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> Business Name (DBA) , _ Address / - <br /> s Owner Address <br /> FIrm Partners, AdOresses and Telephone Numbers <br /> iusiriess Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> ,kpplicants Name (Print) - ••- Title <-- _- _ Date <br /> [lease check Applicable Category (1-7) and,Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> or July 1, June 30, 19 Disposal Sites <br /> )escription(Make/Yr., Calor) <br /> serial No. CAL. License No. CAL. License Renewal No, <br /> Capacity Gal.,Weights&Measures No. <br /> quipment Parking Address <br /> ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> Jo.of Vehicles Storbd <br /> lo. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST <br /> F.S. or R.C.E. Name R.S.or R.C.E. No. <br /> est Location Test Date/Time <br /> �. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> 5)caner ;� : -- t,l ,. i i_•y. S� .. Address :. �' ;�_. i,.fs, �,• <br /> 3 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING WELD - ❑ SEEPAGE PIT ` ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 0 NEW ❑ REPAIR ❑ OTHER <br /> F ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 'ype Construction Disposai.Site <br /> No. of Units Equipment Sto_ rage/Gleaning Locatiori(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> 'perator Name Where Certified <br /> dant Location <br /> Plant Capacity No. Units Served <br /> F ❑ LAUNDRY For July 1,-June 30, 19 <br /> IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. 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 /> 4 ordinances, state laws, and,Crules and regulations of the Sap Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOA DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1!<Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE- DATE REMITTED AMOUNT DUE CHECKHD <br /> AMOUNT <br /> ` FEE <br /> LESS <br /> y PRORATION <br /> PLUS <br /> PENALTY <br /> I, OTHER I <br /> OTHER <br /> i <br /> +. Received TYDate Receipt No_ r' i1 Na - --—--lywance Date Mailed —Deliverep j <br /> - -__-— ...+�.mow.....r .... .._...w.. a vT1',N ,-•6C'M1 . <br /> I <br />