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Applications Will Be Processed When Submitted ProperlyCompletea. uesure tvaly++ <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby made to carry on businessin the juri dictional area of the San Joaquin Local Health District„, <br /> Address <br /> 'Business Name (DBA) 7 _ <br /> r ,Q Address t� <br /> zz Owner <br /> u Firm Partners, Addresses and Telephone Numbers , <br /> aBusiness Telephone No. `�! CIS Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) <br /> Title �' Date a <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 /> CAL. License No. CAL. Licc:lse Renewal No. <br /> Serial 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 ` p <br /> 3. ❑ PERCOLATION TEST p, <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> 1, Test Date/Time <br /> Test L9eatian _ <br /> 4. W SANITATION PERMIT ;np <br /> Job Address/Location <br /> Owner 1 Address 101POTHER <br /> A AGE PLANT <br /> 93"SEPTIC T ❑ CESSPOOL NEW FIELD SEEPAGE PIT ❑ <br /> LS PERMANENT ❑ TEMPORARY NEW + EPAIR� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19H�� ! <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 <br /> PNo. Units Served <br /> Plant Capacity <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and rules a regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received�REMITuly 31 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CDATE DATE REMITTED A <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AYE.,P .Bo■2009 STOC TON CA 95 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES /�t�� <br />