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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 /> Application is here made to carry n b iness in the jurisdictional area of the San J uin Local Health District <br /> NBusiness Name (DBA) O Address <br /> z Owner Address w <br /> X <br /> Firm Partners, Addresses and Telephone Numbers <br /> E. Business Telephone No. — Emergency Telephone No. <br /> a <br /> Contractor Licence Na <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> i 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.No. <br /> R.S. or R.C.E. Name <br /> LI <br /> Test Date/Time <br /> Test Location <br /> 4. 53 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address F <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW , }� REPAIR ® OTHER SI 1f <br /> 'f 5. ❑ CHEMICAL TOILETS For July 1,=June 30, 19 <br /> r Disposal Site - <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19• _-. <br /> Operator Name <br /> 110- <br /> Where Certified <br /> Plant Location i <br /> 'Plant Capacity - No. Units Served <br /> 7. ❑ LAUNDRY For July 1, June 30, 19 m <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft. LI ' <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> K <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San quin County <br /> ordinances,state laws, and r es and regulations the San Joaquin Local Health District. <br /> E t <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> F4EE <br /> IDue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceweRdEBy July 31 r°e <br /> BASE EXPLANATION MIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> f OATS DATE REMITTED AMOUNT .. <br /> J �v I <br /> � )1✓ T <br /> Received by Date - Receipt No. Permit No. I Issua ce Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O2009$r 7 KTON,CA 95201 <br />