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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneAppncauun. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is �erebym��adeto <br /> �on bus' ess in the jurisdTonal area of the Soaqu Loc��ealth DistriwBusiness Na DBA) Address ` <br /> I- Address <br /> z Owner <br /> a <br /> JFirm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 13E'g ��� � Emergency Telephone No. <br /> Contractor Licence No. <br /> L 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 /> J <br /> For July 1, June 30, 19 Disposal Sites 7 <br /> 1 ti <br /> Description(Make/Yr., Color) <br /> Serial No. GAL. License No. CAL. License Renewal No. <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. No. <br /> R.S. or R.C.E. Name <br /> TTest Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT 1 <br /> Job Address/L ation � <br /> Ow�r Address <br /> Ifs SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EPAGE PIT ❑ PAGKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 9—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 t <br /> Plant Capacity s No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 A <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 glarnd <br /> ed this application and that the work will be done in accordance withSanJoaquin County <br /> ordinances, state laws, a regulations S Joaquin Local Health District. <br /> PPLfCANT'SSIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED \AKNNT <br /> FEE O o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ) / <br /> Received by� Y ,Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.D.Box 2009 STOC TON,QA 524) <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT7SERViCES e {f? <br />