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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 /> s <br /> Applildatiorjishereb Pa eto rryo b siness in the jurisdictional area of the n Joa in Local Hea District ' <br /> y Business a (DBA) A ddre 21 <br /> z Owner E Address r <br /> U Firm Partners, Addresses and Telephone Numbers Pr-k <br /> ,3 6bl <br /> Emergency No. <br /> EL Business Telephone Na: 9enc Telephone Y P - <br /> Contractor Licence No.. <br /> Applicants Name (Print) Title e4y" Date <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 Disposal Sites CV <br /> I Description(Make/Yr., Color) <br /> E Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address l t ! <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT / <br /> Job Addres Location S ( <br />' Owner Addr4ss ����� • - C <br /> B"SEPTIC TANK Ll CESSPOOL ['"LEACHING FIELD CYSEEPAGE PIT ❑ PACKAGE PLANT r� <br /> B"PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> Operator Name Where Certified <br />} Plant Location at <br /> Pf <br /> ` Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> f SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have are this pplication and that the work will be done in accordance with San Joaquin County ' <br /> ordinances, state laws, an es and re ns f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> f <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0 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 CHECKED <br /> y HATE DATE REMITTED AMOUNT <br /> 1� FEE <br /> rPRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a <br /> 55 <br /> -749 -,3 Z <br /> Received by Date Receipt No. Perm't No. Issuance Date Mailed eliver <br /> APPLICANT—RETURN ALL COPIES TO: ENYIRONME TA HEALTH PERMIT/S ICES isol E.HAZELTON AY Box 2 5T CKT N,C 20 <br />