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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> '- ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica is he by de r_ry on busi ess in the jurisdictional area of the San �uisnLocal Health Dst c �T <br /> yBusiness Name (DBA) _ l� Address <br /> z Owner Address <br /> d <br /> Firm Partners, Addresses and Telephone Numbers <br /> Ill a. Business Telephone No. Emergency Telephone No, <br /> a 6 <br /> Contractor Licence No. —, c7 <br /> LApplicants Name(Print) rl ail Title S Date <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 /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. M <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 <br /> 3. 11 PERCOLATION TEST I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMI <br /> Job Address/Location <br /> Owner lly 00g24&M 4 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ` LEACHING FIELD ;SEEPAGE PT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 4 <br /> Type Construction Disposal Site <br /> No. of Units I Equipment Storage/Cleaning Locations) <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 <br /> 7. ❑ LAUNDRY O'For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r� <br /> ❑ DRY CLEANING;Chemicals Used/Amount/Mo. <br /> ` } <br /> + I,hereby"certify that_1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> } ordinances, state laws, s and regulation -of the Sa Joaquin Local Health District <br /> t <br /> APPLICANT'S SIGNATURE �'" <br /> i <br /> 1000' <br /> L--- - FOR DEPARTMENT-USE ONLY <br /> ----�---- �w <br /> Fee IS Due: ❑ ANNUALLYf ❑ PER UNIT ux PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE 'DATE REMITTED <br /> J" AMOUNT <br /> � FEE `µ` } � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY , <br /> s r � <br /> OTHER <br /> OTHER <br /> E] <br /> Received by Date Receipt No. Pe it No. Iso nce ate Mailed y0elivre�d .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1641 E.HAZELTON AVE.,P.O.Box 200995201 <br />