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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />-r Non -Transferable, Revocable, and Suspendabi., SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />is <br />area of <br />m Business Na-�[�D�ByA� IL ( -re-_/ /Ad res <br />) <br />I ; I f ( <br />-� <br />aOwner t / h/r !� ?� �� G A dress / <br />C <br />Firm Partners, Addresses and TelephgRp, N bars <br />'n L�y <br />_ <br />Business Telephone No. - Emergency Telephone No. <br />a cc <br />Contractor Licence No.� [— <br />S <br />Applicants Name (Print) f f f )L 1LS� I C-. Title <br />Date <br />Please check Applicable Category (1-7) and Fill In the Required Information <br />E%PLANATION <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />REMITTANCE <br />For July 1, June 30, 19 Disposal Sites <br />AMOUNT DUE <br />Description (Make/Yr., Color) <br />Serial No. CAL. License No. <br />CAL. License Renewal No. <br />Capacity Gal., Weights & Measures No. <br />DATE <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />FEE. <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />0 0 <br />No. of Chemical Toilets Stored <br />— <br />3. ❑ PERCOLATION TESTyy <br />A J. <br />R.S. or R.C.E. Na%ne R.S. or R.C.E. <br />o. <br />Test Location Test Date/Time <br />4. ❑ SANITATION PERMIT <br />PRORATION <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br />❑ PACKAGE PLANT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br />❑ 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 />PENALTY <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name <br />Where Certified <br />Plant Location <br />OTHER <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 />OTHER <br />I hereby certify that 1 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 A Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />E%PLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE. <br />0 0 <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 />