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LL Applications Will Be Processed When'Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE F <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to tarty on business in the jurisdictional area of the Sa oaquin Local Health District `s <br /> nBusiness Name (DBA) Address C <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> • { Emergency Telephone No. S <br /> CL Business Telephone No. _ <br /> Contractor Licence No. <br /> Title — Mme' Date <br /> LApplicants Name (Print) i <br /> Please check Applicable Category (1-7)and Fill in the Required Information y '� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST – w.r <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E`Name <br /> I Test Location Test Date/Time \Lv <br /> 4. ❑ SANITATION PERMIT 4 -1l <br /> CAJob Address/Location <br /> Owner _- Address ❑ PACKAGE PLANT t 1 <br /> 11 SEPTIC TANK 11 CESSPOOL C1 LEACHING FIELD D SEEPAGE PIT <br /> 11 PERMANENT 11 TEMPORARY 13 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. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 T <br /> L :�: A I.. .,Where Certified <br /> Operator Name { <br /> Plant Location �. <br /> Plant Capacity - No. Units:Served <br /> f .:. <br /> 7. ❑ LAUNDRY For July 1, -June 30;19 t <br /> I SIZE:' ❑ t^ess Than 1ti000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. J e <br /> k <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and/rules and rpgulatlonF Of the SarLJoaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> 3 FOR DEPARTMENT USE ONLY <br /> t` Fee Is lDue: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 99 BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS — <br /> PRORADON - <br /> PLUS <br /> PENALTY <br /> 1' OTHER <br /> f OTHER <br /> Received by Date Receipt No. <br /> - ermit No. Issuance Date Mailed D re <br /> �. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 ST III CA 95201 <br />