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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. u <br /> APPLICATION <br /> • (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio 's eby 09 arty bus' a in the jurisdictional area of the San uln al H Ith Distric <br /> y Business Na (DBA) <br /> r- r A dress <br /> a Owner ct Ad ress l/ <br /> Firm Partners, Addresses and el phone Numbers £ - 4/ _%"O' 11 <br /> CL <br /> Business Telephone No. T9 F, 3�3 Emergency Telephone No. <br /> j Contractor Licence No. 5d <br /> L Applicants Name (Print) Title Date �`Za <br /> Please check Applicable Category (1-7)and Fill in the Required Information t <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, Liccnse 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. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT �� n �� ���• 3��� <br /> Job Address/ cation Iv <br /> Owner Address 4 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ` SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY 1:1NEW 4/REPAIR ❑ OTHER Q <br /> 5. ❑ CHEMICAL.TOILETS For July 1, -June 30, 19 O' <br /> Type Construction Disposal Site (("l, <br /> No. of Units Equipment Storage/Cleaning Location(s) E <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 40 <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 Ihave par this applicatio nd hat he work will be done In with San J aquin County <br /> ordinances, state laws, an ules d regulations e J quin 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 ed By January 31 / ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received b �� <br /> Y Date Receipt No. Permit No, Iss ante D ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BoxMaile2009 STOCKT N,CA 95201 <br />