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Applications Will Be Processed When Submitted Properly-Completed. Be Sure To Sign The Application. <br /> ArPPLOCATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ' a ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl'icatio h reby ma o car busi s in the jurisdictional area of the San Joa in al al Di �] <br /> y Business me (DBA Addr 6 r "C! <br /> aOwner Address - } <br /> 9 Firm Partners, Addresses and Telep e Amb <br /> a Emergency Telephone No. <br /> CL Business Telephone No. ,J <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date Q <br /> Please check Applicable Category (1-7)and Fill in the Required I formation <br /> 1. ❑ 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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD (��( <br /> For July 1, June 30, 19 V <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. <br /> Test Location Test Date/Time _ <br /> 4. 0 SANITATION PE I t <br /> Job Ad s/Lo a ' n q <br /> Addres <br /> Owne <br /> s w <br /> .SEPTIC TANK ❑ CESSPOOL LEACHING FIELD C3SEEPAGE PIT 13PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 [ I <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 I <br /> Operator Name Where Certified <br /> Plant Location i <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 /> r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> 5 <br /> 5 <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 es and regulatio -of the Sa oaquin Local Health District. <br /> r ' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY pS <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 # <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKEp <br /> DATE DATE REMITTED AMOUNT <br /> FEE _ o <br /> LESS d <br /> PRORATION <br /> rl ('12 <br /> PLUSPENALTY <br /> OTHER <br /> OTHER <br /> 6 ,?r2-- <br /> Received by Date Receipt No. Permit No. Iss ance Date Mailed,, e rve d <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITfSERYICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 5T0 TON,CP95 <br />