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Applications Will Be Processed When Submitted Properly Completed. <br /> t APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) V� SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Healfh'17istr`t �& <br /> Address <br /> y Business Name (DBA) r i <br /> Address ''` <br /> z Owner <br /> a <br /> J Firm Partners. Addresses and Telepho Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence Na _ Title �* � - Date <br /> LApplicants Name (Print) `� In t <br /> Applicable Category(1-7) and Fill in the Required Information Q 1 <br /> Please check App� , <br /> 1. ❑.PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) , <br /> For July 1, June 30, 19 Disposal Sites _ \j <br /> moi ? _ <br /> Description CAL.Color) _ _ ry y '_- -CAL. L-icense Renewal No. <br /> —GAL--License No - =' "# <br /> Serial No,— 'p. <br /> Capacity Gal.,Weights &Measures,No. --� - <br /> Equipment Parking Address <br /> tM <br /> 2. ❑ PUMPER YARD ",,.'... <br /> For July 1, June 30.19 <br /> No. of Vehicles Stored '� F <br /> No. of Chemical Toilets-Stored- <br /> 3. ❑ PERCOLATION TEST <br /> 4. R.S.or-R.C.E. No. <br /> R.S.or R.C.E. Name' Test Date/Time` * <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Address <br /> OOwnEACHING FIELD © SEEPAGE PIT El PACKAGE PLANT ; <br /> L+ SEPTIC TANK 13 CESSPOOL ❑ OTHER 3 ` <br /> ❑ TEMPORARY ❑ NEW C3 REPAIR <br /> + t <br /> 11 PERMANENT o°,-i k <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �j .� <br /> Disposal Site <br /> Type Construction ' <br /> No. of Units; Equipment Storage/Cleaning'-Locations) <br /> Ir <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified:` <br /> Operator Name <br /> Plant Location �.� 'No-Units Served <br /> Plant=Capacity <br /> 7. ❑:LAUfyDRY For July,1,-'June 30,19 �..�. <br /> SIZE: ❑ ;Less Than 1,000 Sq. Ft., C3 More Than 1,D00 5q. Ft. g j <br /> k - ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - _ - <br /> f <br /> +i <br /> 11-hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqu Cqunt <br /> ordinances, state laws, and ru'le's and gulatio f the San Joaquin Local Health District. <br /> F APPLICANT'S SIGNATURE X <br /> 1 4 <br /> FOR DEPARTMENT USE ONLY <br /> �r ❑ Januar 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due- ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Y REMIT <br /> }} BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE 1 EXPLANATION DATE DATE REMITTED AMOUNT <br /> z <br /> x <br /> FEE <br /> t <br /> LESS <br /> PRORATION <br /> l <br /> PLUS <br /> PENALTY -- <br /> [ F- <br /> Y <br /> OTHER <br /> � 1ssuance ate Mailed Delivere <br /> Received 6y <br /> Date s Receipt No. _ Permit No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES. 1601 E.HAZELTON AVE.,,P.O.Box t19 STOCK ON,CA 526 <br />