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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION nn <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE y <br /> ENVIRONMENTAL HEALTH PERMIT j <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 1n Business. ame (DBA Address <br /> z Owner I�� Address 32 2, o 4 e <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) CA �s t7v— Title '� Date <br /> Please check Applicable Category (1-7) d 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 /> Serial No. CAL. License No. CAL. License Renewal No. S <br /> Capacity Gal., Weights &Measures No. z <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD Q <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <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. ❑ SANITATION PERMIT Q <br /> Job Add s/�ocation 7z-14 e b ` <br /> Owner E e Address z0b/ <br /> / <br /> .SEPTIC TANK ❑ CESSPOOL LEACHING FIELD &SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19.PERMANENT ❑ TEMPORARY 9 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 I <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I h e pr pared this application d that t e work will be done in accordance with San Joaquin County <br /> ordinances, state I an rapd regula 'o 's of ocal Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT OPER 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 <br /> i <br /> r <br /> FEE S " S <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rti—. 1 1 777 9 <br /> Received by Date Receipt No. Permit No <br /> Issuance Date Mailed D5/ 4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �_, 1601 E.HAZE TON AVE.,P.O.Box 2009 S ,CA201 <br />