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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign IneAppesanvn. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applican—ewal.. <br /> ereJ�y made to carry n�,usiness in the jurisdictional area of the pan Joa uin Local Health District <br /> Business Name (DBA) f Address. r-Q• e- <br /> x Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers O <br /> d Business Telephone No. 'g Emergency Telephone No. ) <br /> -J Contractor Licence No. <br /> Applicants Name (Print) -0���£ .3�fI►J rT• - Title s- %--- Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information Q6 <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.G.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time r <br /> 4. )? SANITATION PERMIT 71 <br /> Job Address/Location avf <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ 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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ides and regulations the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By ary 31 ❑ July i &Recew dBy July 31 <br /> REMIBASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> PATE DATE REMI E �¢ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 7 S <br /> Received by Date Receipt No. Permit, I ua�ate Mailed elivere Z <br /> APPLICANT—RETURN ALL COPIES 7O: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.aox 2009 STOCKY N.CA 9 201 <br />