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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />or Non -Transferable, Revocable, and Suspenda SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application is eby) car bus e s t e isdictional area oft Jo in Local D' trict <br />wBusiness Nam DBA aAd res- <br />14 <br />S7- <br />1- Owner dress <br />a <br />Firm Partners, Addresses Brill Teleph N bers <br />E Business Telephone No. Emergency Telephone No. 86 in ZCIP - <br />Contractor Licence No. - <br />L Applicants Name (Print) I I ! �� S _L(,/J-i-V Title _-1IL� Dat <br />Please 6heck Applicable Category (1-7) and FIII 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. <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 TES S —�� -7 <br />R.S. or R.C.E. Nape Z0,11 A R.S. or R.C.E. No. <br />Test Location Test Date/Time _ t7,'4f�M <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br />❑ PERMANENT ❑ TEMPORARY ❑ 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 <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 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 of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 a Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE $ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE REMITTED <br />AMOUNT <br />FEE <br />S .� <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />\ (� <br />Received by - ate Receipt No. Permit No. Issuance Date Mailed Delivered <br />.............. ...... ,o.. ..... u.sn rnu eve en c... none .mramu re..om <br />