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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ^ <br /> Applicati n is her made to ry on siness in the jurisdictional area of theaSan Jo�tuin Local}iealt District l/sem/ <br /> n Business N (DBA) Addre (� !'a� <br /> e Owner Address f <br /> a GIL <br /> Firm Partners, Addresses and T eph0ne Numbers M JE <br /> L Business Telephone No. ZC4 Emergency Telephone No. ` <br /> Contractor Licence No. O sS 79 <br /> L Applicants Name (Print. <br /> Ce Title SNµ Date v <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 /> Description(Make/Yr.,Color) <br /> Serial No. CAL.License No. CAL License Renewal No. <br /> Capacity Gel..Weights 8 Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD sA W <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored .T <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E. Name R.S-or R.C.E.No. — — <br /> Test Location _ Test Date/Time <br /> 4. ffSANITATION PERMIT y'b <br /> Job Add re /Location K <br /> Owner AN Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD �S SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW ia-REPAIR ❑ OTHER ��7771II <br /> 5. 13 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. EI PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 pre red this ap 'cation and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and and regula I e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t a Recalved By January 31 ❑ July 1 &Raceiv REMITBy u1Y 31 - <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE !J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - 0 9 <br /> Recelvell DY Date Receipt No. Permit No I uan Date Malleo trT.,dAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITBERVICES1501 E.NAZELTON AVE..P-OBoa Ra09 ST <br />