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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION - ±" -•I <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE I <br /> LIQUID WASTE <br /> Applicatio he y ade to carryon bus'Ress in the jurisdictional area of the San Joaquin„l ac It is ct 6 <br /> w Business Na ) Address <br /> z Owner dAddress <br /> Q <br /> 2 Firm Partners, Ad Jr, and Telephone Numbe <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. on <br /> 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) O <br /> For July 1, June 30, 19 Disposal Sites l� <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. LiccnSe Renewal No. <br /> Capacity Gal., Weights & Measures No. ` <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD J. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ILo ation_ V� <br /> Owner Address <br /> ISEPTIC TANK ❑ OtSSPOOL LEACHING FIELD ❑ ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARYAA NEW ❑ REPAIR ❑ OTHER <br /> 5. E] CHEMICAL TOILETS For July 1, -lie 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/Amount/Mo. �- <br /> i � 1 <br /> 3 r <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, an rul nclulation of a San J:�zz <br /> Ith District, <br /> APPLICANT'S SIGNATURE X � <br /> 1-7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE I/ <br /> LESS <br /> PRORATION <br /> PLUS - ' <br /> PENALTY 'rte �1 <br /> OTHER <br /> OTHER <br /> �1� ►�79 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed 4tirAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 95201 - , <br />