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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppucation. <br /> APPLICATION <br /> .(For Non-Transferable, Revocable,and Suspendable) <br /> f� ENVIRONMENTAL HEALTH PERMIT SEPTAGE i <br /> LIQUID WASTE <br /> Application is h by made t ry b sinein he juris tional area of the San Joaquin Local He str' <br /> W Business Na e,D ) Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Num ers <br /> aEmergency Telephone No. <br /> a. Business Telephone No. -. <br /> a Contractor Licence No. <br /> �Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Requir Information <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 ' <br /> No. of Vehicles Stored <br /> k 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 LocatWn <br /> ` Owner Address <br /> 13 SEPTIC TANK ❑ CESSPO LEACHWG FIELD SEEPAGE PIT ElPACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY E] NEW REPAIR ❑ OTHER <br /> 5. 13 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 <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. , <br /> I hereby certify that I have prepared this appli and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r an a ulatio of t e San Joaquin Local H h District. <br /> APPLICANT'S SIGNATUREX., <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ AN ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REM4TTED AMOUNT <br /> �f5 <br /> FEE 00 4 5 ° ° <br /> -' <br /> F LESS , <br /> f PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> 9' 7 ?� a115 1 a. <br /> Received by Date Receipt No. Permit Na. Issu nce Date Mailed Deliv etl <br /> 1601 E.HAZELTON AYE.,P.O.Box 2009 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 570CKTON,CA 95201 <br />