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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppucanon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE° <br /> Application i here Ode to carry�bln�essihe jurisdictional area of the San Joaquin Local Health District;Business Name (DBA)z Owneress <br /> a s . <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No- -9 Emergency Telephone No. <br /> Contractor Licence No. <br /> � <br /> Applicants Name (Print) o <br /> Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER.VEHICLE PERMIT REG ISTRATIQIC(FOREACH VEHICLE) <br /> �. '. '"D.— osal Sitesc <br /> For July 1, June 30, 19 l <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL. License No., <br /> Capacity Gal.,Weights R 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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEP C TANK ❑ CE SPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 13 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 /> P <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 regulatio the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Are a ol <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 8 ReceivedREMITuty 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY- <br /> OTHER <br /> OTHER - <br /> `73 SZ <br /> :e Received by Date Receipt No. Permit N. Issuance Date Made elivered' <br /> TH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.av:2009' S70CKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEAL <br /> f <br />