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Applications Will Be Processed When Submilled Properly Completed.Be Sure To Sign The Application. f <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is hele¢y ma to on uslness in the jurisdictional area of the San Joaquin Local Healt istrict <br /> if <br /> Business Name BA � - �- — Address j O J t.f�` "�} <br /> Jwner S ��,� �•� O Address - <br /> -irm Partners.Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. -- <br /> Contractor Licence No. 0 1 _� S Date <br /> Applicants Name (Print) Title <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) -- i <br /> For July 1, June 30, 19 Disposal Sites <br /> 1 <br /> Description(Make/Yr.,Color) CAL.License Renewal No. <br /> Serial No. CAL.license No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address ) <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST A.S.or R.C.E.No. <br /> R.S.or R.C.E.Name <br /> Test Date/Time <br /> Te t Location <br /> 4.)C SANITATION PERMIT <br /> Jots AddressL calioq <br /> Owner Address <br /> }o.SEPTIC TANK O CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT W <br /> ❑ REPAIR ❑ OTHER 0 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 CW ' <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 Where Certified <br /> Operator Name <br /> Plant Location _ <br /> No. Units Served <br /> Plant Capacity - <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. 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 /> E ordinances, state laws,and rule;and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITF ❑ EACH Q January 1&Received By January 31 ❑ July 1&Received <br /> By July 31 <br /> REMBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Wi <br /> I LESS t! <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER .l�L <br /> OTHER r G <br /> jY! - /55 -la <br /> Received by <br /> O t Receipt No. Permit No. Issuance Date ail Delivered <br /> � APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., Bo Di STOCICTON,CA 95401 <br />