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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 />the jurisdictional area of <br />rn Business-�Iam{e-y(DBAL- <br />aOwner ' ' Nf��C� 5 �r � ddress <br />Firm Partners, Addresses and Tejeph>9ge Num <br />aBusiness Telephone No. ll��-- <br />Contractor Licence No. <br />L Applicants Name (Print) <br />Please check 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. <br />Capacity . <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />CAL. License No. <br />Gal., Weights & Measures No. <br />Emergency Telephone No. <br />Title <br />Date <br />CAL. License Renewal <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TeTSST_ I� s ��( - <br />R.S. or R.C.E. Named �-- 1T����f l�i�i�� R.S. or R.C.E. /No �}..L_, <br />Test Location L o r O r r G Test Date/Time ` <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner <br />❑ SEPTIC TANK <br />❑ PERMANENT <br />❑ CESSPOOL <br />❑ TEMPORARY <br />Address <br />❑ LEACHING FIELD ❑ <br />❑ NEW ❑ <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />SEEPAGE PIT ❑ PACKAGE PLANT <br />REPAIR ❑ OTHER <br />No. of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For: July 1, - June 30, 19 <br />Operator Name _ <br />Plant Location _ <br />Plant Capacity <br />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 />Where Certified <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 It 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 />J <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br />.....r.u.—ocn reu wr 1 rneme rn. cumonuucure' ucnr uevm rnu euc en e.... eernearnu ae tient <br />