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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 Suspends.. SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application is eby e to cara on business in e'urisQictionai area of t In o uin ca ,al Distnc <br />Business Name (DBA dr ss <br />a -,.�/ ) <br />a Owner�LllJri%� I (.� dress 7 Ia1.LV <br />no Firm Partners, Addresses and Tel phone umbers <br />aBusiness Telephone No. Emergency Telephone No. <br />Contractor Licence No. <br />L Applicants Name (Print) Title 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. <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. ❑ PERCOLATION TEsT. <br />A <br />r,�,, -7 <br />R.S. or R.C.E. Name �l E� r R.S. or R.C.E. No/ �G <br />Test Location Test Date/Time 2 <br />4. ❑ SANITATION PERMIT J <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/AmounVMo. <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 X <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />p O <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />C� <br />Received by Daeo Receipt No. Permit No. Issuance Date Mailed Delivered <br />t <br />.... ....... . ..... ..........— — .....,a..u..c.,........... eee...:,.ee..,ec. .... a u.vm mu eve on o,.. amo nmcarnu es "Mt <br />