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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio 's ereby ma to carry op-business in the jurisdictional area of the San Joaquin Local ealth Distri t <br /> rn Business Na a (DBA) w Address <br /> aOwner . Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � �� / Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) Title e�_ Date ) <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> V 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llccnse 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 E. Name R.S. or R.C.E. No. 1 <br /> Test L cation Test Date/Time i,r I <br /> 4. SANITATION PERMIT <br /> Job Addres / ocation .e _ <br /> O�wnJ�� Address <br /> L7 SE CC TANK ❑ CESSPOOL EACHING FIELD f 3–SEEP—AGE 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) J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified i <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s nd regulati ns the Sap Local 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 JuVy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> [�� AMOUNT <br /> fEE 1 /`a <br /> LESS <br /> PRORATION <br /> PLUS ' , L50 <br /> PENALTY v v <br /> OTHER <br /> OTHER <br /> d 7 <br /> Received by Date Receipt No. Permit No. I Issuan a Date Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES 7p: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,C/96201 <br />