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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (Fdr Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h sby made to c rry on busin ss in the jurisdictional area of the <br /> ( A) Sanoaq_uH5h(Dsict <br /> Address <br /> Business Name <br /> Owner Address - �i-Q- <br /> Firm Partners, Addresses and Telephone umbers <br /> Business Telephone No. Emergency Telephone No. <br /> ,J,Contractor Licence No. Z <br /> Applicants Name (Print) Title fW Date <br /> Please check Applicable Category (1-7)and Fill in the Required Into atlon. i <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 ation Test Date/Time <br /> 4. <br /> Test <br /> PERMIT p <br /> Job Addre ocation <br /> OLw'w Address <br /> P ❑ <br /> W E' PTIC TANK ❑ CESSPOOL LEACHING FIELD T PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW " ®REPAIR ❑OTHER <br /> S.. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t <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 /> Operator Name Where Certified E <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. FL <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 ruand regulations of the n Joaquin Local Health District. <br /> s �Q <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑.PER UNIT ❑ PER SITE ❑ EACH ❑ January,1 6 Received By January 31 ❑ July 1 E Received By July 31 f <br /> BILLING REMITTANCES REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED '\ <br /> AMOUNT J`�\ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Y <br /> Received M' Date Reoelpt No. Permit No. ssuanc Date Mailed Delivered <br />