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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspenoai,le) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Applicati>�s¢ereby d to r nib si ness;i the.'urioic <br />F Busin�e /�me 1IDEA) FF--ff a4 S ,J - / <br />a Own r 1'T I/ 15 l cj,5Lk.�) Address <br />%(�] <br />Firm Partners, Addresses and�ho�1. Num I'S <br />$Business Telephone No. <br />1. Contractor Licence No. <br />�A III, III <br />Applicants Name (Print) ' <br />Please check Applicable Category (1-7) and Fill In the Required Information <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. CAL. License No. <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />Gal., Weights & Measures No. <br />area of <br />Emergency Telephone No. <br />Title <br />Date <br />CAL. License Renewal <br />No. of Chemical Toilets Stored3. C + ❑ PERCOLATION p) R.S. or RC <br />S`�4 7 <br />R.S.or R.0ENe eQ�5 <br />Test Location Test Date/Time <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner <br />❑ SEPTIC TANK <br />❑ PERMANENT <br />❑ CESSPOOL <br />❑ TEMPORARY <br />Address <br />❑ LEACHING FIELD ❑ <br />❑ NEW ❑ <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />SEEPAGE PIT ❑ PACKAGE PLANT <br />REPAIR ❑ OTHER <br />No. of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name <br />Plant Location <br />Plant Capacity <br />7. ❑ LAUNDRY For July 1, - June 30, 19 <br />No. Units Served <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />Where Certified <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />p <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />-7 c 1 <br />Received by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br />...... ......� ..�...e., .. , ..,.e.�e r... ..,......,.... — ........ ...r a u.vm mu euv o n .— �. ern,v nr u ce xam <br />