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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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />yBusiness Name (DBA), Addr ss <br />i Owner Address <br />Firm Partners, Addresses A4 Telephone Numbers <br />aBusiness Telephone No. Emergency Telephone No. <br />� r•......e..�... I L.o.,�o Mn <br />Applicants Name (Print) Title 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. <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />Gal., Weights & Measures No. <br />CAL. License Renewal <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST \/ <br />R.S. or R.C.E. Name 3 k f•�� e� �P Q c��ti¢r� R.S. or R.C.E. No. <br />Test Location C1 -o �rao.r� 1-!t­Date/Time _ 3� <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br />S. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />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 <br />Plant Location — <br />Plant Capacity — <br />7. ❑ LAUNDRY <br />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 />No. Units Served <br />❑ PACKAGE PLANT <br />❑ OTHER <br />Where Certified <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 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 8 Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />/ S <br />LESS <br />PRORATION <br />�L <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />ZLA <br />Re iv to Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br />_ . o, , ..,r ecr„o� .,, rnmro m. cuvmnuucure, ucer ru wcwwrrocwmnro yam c uvcr mu evc on w... onno ernrarnu ce uscnt <br />