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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 Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application er by m e to c rty on business in jurisdictional area of the San Joaquin Local Health Dis rlct <br /> rn Business Name (DBA) Address. <br /> aOwner ' Address <br /> J Firm Partners, Addresses and Telephone Numbers W <br /> ! <br /> Emerge <br /> Telephone No. <br /> a Business Telephone No. p Contractor Licence No.Applicants Name (Print) d Date <br /> Please check Applicable Category (1-7)and Fill in the Required Inlormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> i <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. <br /> CAL. License No. CAL. License Renewal No. <br /> Y <br /> Ca acit Gal., Weights & Measures No. <br /> P lf' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD .A <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ' <br /> iF <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. C-SANITATION PERMIT j t <br /> Job Address/Location <br /> Owner - 7 .�G ` Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT I <br /> M-PERMANENT ❑ TEMPORARY WVEW W REPAIR ❑ OTHER _ t <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ` �J <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 /> Operator Name Where Certified — <br /> Plant Location <br /> Plant Capacity No, Units Served I, <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 /> II <br /> hereby certify that I have pr ared this a cation and that the work will be done in accordance with San Joaquin County 'F&i <br /> ordinances, state laws, a re ati s of the San aquin cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> � f <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT i <br /> EEE <br /> LESS <br /> PRORATION t' <br /> i <br /> '. PLUS <br /> PENALTY <br /> OTHER d <br /> e �* <br /> I OTHER <br /> ]c . <br /> r <br /> s <br /> Received by -Date Receipt No. Permit No. I sua a Date ailed Delivere <br /> - 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AY .Ba■2009 S70CKTON,C X520 <br /> t 4. <br />