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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 S n Joaquin Local Health District <br /> yBusiness Name (DBA) 4� Address <br /> z Owner f '- eee <br /> Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. - °>> Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) TitleDate 1 <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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored `S <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. ❑ SANITATION PERMIT / J <br /> Job Address/Location. X_ - <br /> Q,wn Addresses� <br /> !ld'SEPTIC TANK CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW © REPAIR 0-OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> .y <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 /> F � <br /> hereby certify that I have prepared this application and that the work will be doneinaccordance with San Joaquin County <br /> ordinances, state laws, and rules a e on o e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE a � <br /> LESS <br /> PRORATION <br /> PLUS Qy� <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER ... -. - - - - - - - - <br /> i <br /> d 1 '-dbC) J2i <br /> Received by Date Receipt No, Permit No Issuance Date Mailed De red ` <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 ST$fCKTON,CA 95201 ,r / <br />