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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign a PP 1 r <br /> APPLICATION a <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is he/r�nby made to carry on b sines in the jurisdictional area of the S n Jo quir� TpHealt-5District, SZV f <br /> N Business Name (DBA)�� - �5 Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> 0. Business Telephone No. <br /> Contractor Licence No. <br /> Title Date <br /> i <br /> L Applicants Name (Print) <br /> Please check Applicable Category(1-7)ands Pill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 For Bites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No, <br /> CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address a <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ` <br /> No. of Chemical Toilets Stored x j <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. _ <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test�LoIan { <br /> 4. L'� SANITATION PERMIT <br /> Job Address/Location. <br /> Owner �- Address C11\1 <br /> ❑ 5E MANENT TIC TANK 13 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT y� <br /> ,� C1 TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> L�PER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -'June-30, 19 <br /> Type Construction Disposal Site No. of Units Equipment Storage/Cleaning Location(s) �t <br /> 6. C3 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> I' Plant Location <br /> 1 I No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30,119 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certifhat I ha a prepared this aPP ication nd that the work will be done in accordance with San Joaquin County <br /> y t <br /> ordinances, state I es a regu ns of Sa Joaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE <br /> II <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 &ReceiveRd By Juiy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> SD - <br /> FEE <br /> LESS ; <br /> PRORATION <br /> t <br /> PLUS <br /> p PENALTY <br /> r ; <br /> - OTHER s <br /> r <br /> r OTHER - -. <br /> Date Receipt No. ermit No. Issua ce Date Mailed De iv ed <br /> i0.. Received by 1601 E.HAZELTON AVE.,P.O.Boz 2009 STO KTON,CA 201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />