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Applications Will Be Processed When Submitted Properly.Completed. Be Sure To Sign The Application. . <br /> = APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) SEPTAGE <br /> �0 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE .� <br /> Applicati ere y e to carry on usiness.nthe jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA Address T <br /> aOwner - s / <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. �2 Emergency Telephone No. <br /> Contractor Licence No. a o, <br /> LApplicants Name (Print) - S Title - Date ` J <br /> Please check Applicable Category (1-7)and Fill in the Required Information A <br /> 1. [3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) .r <br /> For July 1, Disposal Sites-June 30; 19 p <br /> Description(Make/Yr., Color) <br /> Serial No. s CAL. License No.. CAL. License Renewal No. <br /> Capacity .,GalWeights &Measures No. 1 <br /> i i <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored L. <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 Address/Coca :on <br /> Owner ," y. Address,--��. <br /> E] SEPTIC TANK - ❑ CESSPOOL ❑ LEACH.ING;FIELD ❑ SEEPAGE PIT Q. PACKAGE PLANT <br /> E - <br /> 11 PERMANENT ❑ ❑TEMPORARY NEW i ❑ REPAIR ❑OT, HER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 l <br /> i <br /> k: Disposal Site <br /> Type Construction _ P , <br /> No. of Units Equipment Storage:/Cleaning Location(s) 5 <br /> 6. ❑ PACKAGE TREATMENT PLANT' For July 1, -JtYh8 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 /> 4 SIZE: ❑ Less Than 1,000 Sq" Ft., ❑ More Than-1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> I hereby certify that i have prepared this application that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es nd regulations of e n Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> :F 1 4 <br /> OR.DEPARTMENT USE <br /> Fee Is Due: ❑ ANNUALLY F-1PERUNIT PER ❑ El EAC ' nu 1 .Received By January 31 ❑ July 7 2`.Received By July 31 <br /> REMIT <br /> BASE.'>,-. EXPLANATION BILLING R ' CE $ ,•.AMOUNT DUE ; CHECKED <br /> DATE TEICE <br /> AMOUNT <br /> FEE <br /> PRORATION - - <br /> PLUS <br /> f PENALTY s{ <br /> OTHER <br /> OTHER _ ' - •` t --moi+ <br /> 779— <br /> ti. <br /> Received by Date Receipt No. a Permit No.� l suance _ate Mailed - _ Delivered <br /> " APPLICANT--RETURN-AtL'�COPkES'TO: ENVIRONMENTAL,HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO,,-CA 0 20 <br />