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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppilicaxion. <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> (Applicatio I h rely ma n car busin s In the jurisdictional area of the San Joaquin Lo ,He ti Q <br /> m Business Name BA) <br /> Address ' <br /> z Owner Address <br /> s i <br /> J Firm Partners, Addresses and TeleQhi nUN,umbers <br /> �a Business Telephone No. Emergency-Telephone No. <br /> a <br /> Contractor Licence No. Date <br /> L 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) <br /> For July 1, June 30, 19 T Disposal Sites, <br /> Description(Make/Yr., Color) <br /> Serial No. ,, <br /> CAL. License No. CAL. License Renewal No. <br /> Gal., <br /> & Measures No. <br /> Capacity G Weights <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 it <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> r 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name J <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT e O r <br /> Job Addres Lo ' n 40 <br /> QZ1 <br /> Owner Address <br /> ❑ SEPTI ❑ CESSPOOL LEACHING FIELDSEEPAGE P1T,2 0 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ) NEW Yr REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> Type Construction 1 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <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. <br /> f <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, s and regulation of she Sa oaquin Local Health District. <br /> i <br /> t APPLICANT'S SIGNATURE X <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> orf r, <br /> FEE <br /> LESS <br /> PRORATION { <br /> PLUS ! t0 <br /> y PENALTY <br /> OTHER <br /> OTHER i <br /> Received by <br /> Dale Receipt No. Permit No. ssuance Mailed a sver <br /> Date d <br /> 1601 E.HA2ELTONAVE.,P.O.Box 2009 i TON,CR 2 <br /> APPLtcANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />