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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPUCA��ON <br /> (For Non-Transferable, Rev6ca e,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is by made tp c ry on buess in the)oris fictional area of the a J quin Local Health ict <br /> Business Name (DBA) AddressC. <br /> aOwner t; Address " <br /> Firm Partners, Addresses and T h ne tyer <br /> Business Telephone No. J Emergency Telephone No, <br /> A Contractor Licence No. j <br /> Applicants Name (Print) ! Y4 [1 <br /> _ Title , __ � Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information r �c <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) F M I <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 /> FFor July 1,f June 30, 19 <br /> No. of Vehicles Stored <br /> .No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST '?t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test cation Test Date/Time Nil <br /> 4. SANITATION PER T <br /> Job Addre <br /> Location <br /> Owner Address <br /> . 1SEPTI ANK ❑ CESSPOOL ❑ LEACHING FIELD `' �+SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT, . <br /> ❑ TEMPORARY ❑'NEW REPAIR OTHER K1IZAEW i Ain1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction °� Disposal Site <br /> Norof-Units sem. ' Equipment Storage/Cleaning Locations) s <br /> 6. ❑ PACKAGE TREATMENT_ PLANT For July 1, -June 30_,_19 F <br /> Operator.NameWh <br /> ere Certified <br /> Plant Location y x - <br /> Plarit;:Ca�acit <br /> Y 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. f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. Q — _ <br /> I hereby certify that I have prepared'this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and re ulation a San a uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT.USE-ONLY l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE• []'EACH- '❑,January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> 611-LING .L REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> -- DATE DATE ,REMITTED AMOUNT <br /> FEE <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> ..PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. a mit o. ssuq c 0 e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ` TO .,P.O.Bo>,9009 STOGKTON;CA 95201 <br />