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Applications Will Be Processed When Submitted Properly Completed. taesure Ioatgrr r11w 0. <br /> . <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica{io er m de to carry j�u�I ss in t ignsdictional area of the S quit � Health Distr�c�� <br /> Business NaQBA) <br /> V 1 i �J�4 5 vv d c Address <br /> / r.] /,} <br /> z Owner �wR<e��C Address <br /> a <br /> t u Firm Partners, Addresses and TeleDhone Numbers <br /> a Business Telephone No. :3 ' <br /> ?j- GS Emergency Telephone No. <br /> Contractor Licence No, <br /> I <br /> Title Date <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information i <br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> !; For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Licc.se Renewal No. <br /> Serial No. CAL. License No. <br /> E Capacity Gal., Weights & Measures No, <br /> E 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 R-S. or R.C.E. No. <br /> R.S.or R.C.E. Name <br /> I Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT 8106 /�i/e �41AXc <br /> Job Address/L cation 77x8BS C14 <br /> Owner UA)C IAA) Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER .► <br /> ` 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 � Sf X +1'7 F'�LTC� f � �V �f 1y, <br /> Type Construction Disposal Site �C f <br /> Equipment Storage/Cleaning Locatien(s) <br /> No. of Units O <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity S <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 /> 4 - <br /> Y I hereby certify that I have prepared this application and t t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, anregulationof the S` oaquin Local Health District. <br /> ules and <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Feeds Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIT By July 31 - <br /> _ BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> 114 <br /> �(yj 1•yc �(� , <br /> Issuance Date Mailed Delivered <br /> ' - D to Receipt No. Permit No. _ <br /> Received by .M1 -- 1601 E HAZELTON AVE..P.O.Box 2009 5 KT <br /> APPLICALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ <br /> . p TOC ON,CA° u�� <br />