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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ., <br /> APPLICATION - '" <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> z Owner Address �ma <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a (] J (] Emergency Telephone No. 997-40 9 7 <br /> m Business Telephone No, <br /> Contractor Licence No. + <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. 13 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. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> i <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. O PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> p'. R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> I/F 4. ❑ SANITATION PERMIT <br /> o� O <br /> Job Address/LocaAn Iff,• <br /> caner �J <br /> SEPTIC TANK CESSPOOL EACHIN LD SEEPAGE PIT 0 PACKAGE PLANT rLl�p <br /> TERMANENT ❑ TEMPORARY NEW REPAIR OTHER <br /> i ❑ CHEMICAL TOILETS For July 1, -Jun 30, 19 <br /> C <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 /> f Where Certified <br /> Operator Name <br /> Plant Location <br /> 1 Plant Capacity No. Units Served <br /> i7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo: <br /> r <br /> i <br /> E 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 le reg do sof tOosan Joaquin L ca ealth District. <br /> APPLICANT'S SIGNATURE X <br /> S <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE" $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i � v <br /> FEE <br /> LESS <br /> P,ORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � <br /> 9 --g-7,5 <br /> ' Received by Date Receipt No. Perms[N. Issuance ate Mailed De wer <br /> .. <br /> 1601 E.HAXELTON AVE.;P.O.Box 2009 STOC ON,C} 520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />