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'Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> .� (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> � <br /> LIQUID WASTE <br /> { <br /> ApplIcatio is rereby d arty o us in the jurisdictional area of the 5�n Joa Gn L al F�ealth Di ct <br /> O Business e �OK3A) q� Address C!� , <br /> Address <br /> a Owner ~,� j/ <br /> J <br /> Firm Partners, Addresses and j lephone Numbers <br /> a Business Telephone No. (o Emergency Telephone Na <br /> a1 <br /> Contractor Licence No. 7 Date 041/ <br /> Applicants Name (Print) ze <br /> Title <br /> Applicable Category (1-7)and Fill in the Required Information <br /> Please check Appi <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -, <br /> For July 1, June 30, 19 Disposal Sites <br /> i <br /> Description(Make/Yr., Color) CAL, License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br />}' 4. M,9 NITATION PERMIT <br /> f Job Address/ cation 01 <br /> t ..��� Addressl6 <br /> Owner ��" ❑ PACKAGE PLANT <br /> ��EPTIC TANK( ❑ CESSPOOL ❑'LEACHING FIELD EEPAGE PIT <br /> 0;-P ❑ OTHER <br /> €RMANENT ❑ TEMPORARY ❑ NEW 14-REPAIR <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 L/ <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 Where Certified <br /> Operator Name i <br /> Plant Location <br /> I No. 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 /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I <br /> 1 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, and rules and regulations o an aquin Local Health District. it <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'.&RecewendEB�y July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> a FEE <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> jDate Receipt No. Permit No Iss ance ate Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16o1 E.HAZELTON AVE.,P.O.Box 2409 STO—pr <br /> CKTON,CA 95201 <br /> `r177 <br />