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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign IneAppimdtiv- <br /> r APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Ap}'cgtion is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name ( BIS) �-� business <br /> Address 44_<-_0 <br /> z Owner Address <br /> a <br /> J <br /> Firm Partners, Addresses and Telephone Numbers <br /> a C Emergency Telephone No. <br /> a Business Telephone No. _ <br /> Contractor Licence No. Z S <br /> Applicants Name (Print) M S Title �T/ pate <br /> Please check Applicable Category (1-7) and Fill in the Required Information C1\ <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 /> 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 Loc tion Test Date/Time / <br /> 4. SANITATION PERMIT <br /> Job Address/Location ��-� � 1 e' <br /> Owner I Address <br /> 99-SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD 2-SEEPAGE PIT ❑ PACKAGE PLANT <br /> O-PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site "`fl <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name rn <br /> Plant Location r <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 application and that thA work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r les and re ations of San J�in LI Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ 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 /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuan e e iled Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16011 HAZELTON AYE.,P.O.Box 2009 STOM A 95201 <br />