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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign theHNNrr�p �• • <br /> t APPLICATION <br /> (For Nan-Transferable,Revocable, and Suspendable) SEPTAGE <br /> it ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> I Appl icatio is hereby ade to car n bu ine in the jurisdictional area of the Sante aqui Local Health District <br /> Addr ss <br /> m Business N (DBA) 01 <br /> c Owner <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No_ f14 <br /> aBusiness Telephone No. <br /> Contractor Licence No. p s'7a/ <br /> Title Date <br /> Applicants Name (Print) e-�� � <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 S <br /> c Description(Make/Yr., Color) <br /> CAL. License No: CAL. License Renewal No. F <br /> Serial No. �J <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> j 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test LL ation Test Date/Time <br /> 4. SANITATION PERMIT p/ � � - �t <br /> Job Address/Location <br /> i Owner - Address <br /> S'SEPTIC TANK ❑ CESSPOOL LN LEACHING FIELD ET SEEPAGE PIT ❑ PACKAGE PLANT <br /> 21PERMANENT ❑ TEMPORARY 9'FJEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction .Disposal Site <br /> R No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified 1 <br /> Operator Name <br /> t. Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30. 19 f <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t <br /> f I hereby certify.41riat 1-have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule d regulation f e an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY78y <br /> Fee Is Due:'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Receiv REMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE y-4 a EXPLANATION DATE DATE REMITTED AMOlj4jT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t OTHER - - <br /> OTHER <br /> Date Receipt No. Permit No: - Issuance Date Mailed Delivered - - <br /> Received by <br /> .,.. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,AYEP.O.aoK 40S _ SO�TOj A 9520 y <br />