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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 /> f- LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) 711Address <br /> z Owner oma+ Address,. 0 <br /> Firm Partners, Addresses and T.e eph a umbers <br /> a Business-.Telephone No. Emergency Telephone No. - <br /> a1 . <br /> n, <br /> Contractor Licence No. <br /> Applicants Name Title r"'.1 Date "' r <br /> Please check Applicable Catego_ry-(1-7):andFill i he Required Information s 1 ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,'19- -- Disposal Sites = �l <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. El PUMPER YARD ► 5 <br /> For July 1, June 30, 19-� i 4 <br /> No. of Vehicles Stored + <br /> No. of Chemical Toilets Stored ` r <br /> 3. ❑ PERCOLATION TEST <br /> y M <br /> R.S.or R.C.E. Name R.S. or RiC.E, No. i <br /> Test Location Test Date/Time Y r`_ x <br /> f.. <br /> 4. ❑ SANITATION PERMIT ) / 41—, f 3 <br /> Job Address/Location <br /> Owner <br /> G Address fir/ �• e �~ �` <br /> 1P,-9tPTIC TANK ❑ CESSPOOL bi-LEACHING FIELD ❑ SEEPAGE PIT} ❑ PACKAGE'PLANT ; <br /> ❑ PER_MANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR '%Ft 13-OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> '.;i <br /> No. of Units Equipment Storage?Cleaning Location(s) <br /> 6. ❑'PACKAGE TREATMENT PLANT For,July 1, -June 30, 19 "' <br /> Operator Name l i Where Certified..... - <br /> ' Plant Location <br /> Plant Capacity No. Units Served es ' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19'— <br /> 'SIZE: <br /> 9'SIZE: ❑ Less Than 1,0bo Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. s <br /> I hereby certify.that I have prepared this application and that theF work-vuill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re lat qns of the San Joaquin Local Health District!i <br /> APPLICANT'S SIGNATURE X - <br /> ri <br /> FOR DEPARTMENT USE ONLY F x I <br /> Fee Is Due: ❑ ANNUALLY ❑.PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received-By'Jantiary 31 ❑ July 1 &Received By July 31 <br /> t $• REMIT e <br /> BASE EXPLANATION DATE DATE BILLING REMITTANCE REMITTED AMOUNT DUE CHECKED.. AMOUNTtivS <br /> FEE �. t i L6 SS <br /> LESS ' <br /> PRORATION , T. <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> i <br /> z F +t <br /> OTHER <br /> N. <br /> Received by Date Receipt No. Permit No, sua t"Date_ Mailed. Delivered] <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.-Box,2009 //))STOC�K'�[T/�ON,Ij,CA 9520101. ff <br />