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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �fCio APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 1 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name Address 4-24- <br /> aOwnerAddress Z GO/ S [/,�i�n �� man til 9 L <br /> J Firm Partners,, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) .�oli. M L-on s Title C'r'' / �� � 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 /> 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 /> Afs. or R.C.E. Names�ALi,�2 B:& or R.C.E. No. /c,70 S <br /> Test Location Z 2 ZQ/ s i��1�s12fc cu fir/ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 /> Operator Name Where Certified <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 /> Home owner or licensed agent's signature corti`ies tho followir•.tt:"!certify+h?!in the performance of the work for whi:h this permit is issued,I shall not employ any p <br /> in such manner as to become subicct to wumojarl'; <br /> Contractor's hirin or gut-comm-ceinS =u•'--'-rc art`• +ion:n�: I^„rtili that 1n Lht;parformanco c'tha work for which this permit is issued,I shal <br /> employ persaar:;uu?ect to workinan's <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, an rules and regulations of the San Joaquin 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 JL <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKE: <br /> DATE DATE REMITTED AMOUN- <br /> FEE a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br />