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IJ <br /> APPLICATION <br /> (For Non-Transferable,".evocable,and Suspendable) ) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT (/ <br /> LIQUID WASTE <br /> F; Application is h. by made to carry business in the jurisdictional area of t5�an oaqu�Logi Health Distri ts�� <br /> Business Name (DBA) } 4T ' • Address y-"'S'`yF��J (, •' x' <br /> ~_Owner Address <br /> Firm Partners. Addresses and TeleQWne Num e <br /> a Business Telephone No. �'b Emergency Telephone No. <br /> r <br /> Contractor Licence No. _ pate <br /> Applicants Name (Print) Title c�1 <br /> 1 Please check Applicabie 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 t, <br /> Description(Make/Yr.,Calor) <br /> CAL. License No. CAL.License Renewal No. <br /> Serial Na. � <br /> F411 <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 /> A.S.or R.C.E.Name <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT f _. <br /> Job Addre Location + , <br /> Owner a Address <br /> �t LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PL NT <br /> • qI4 SEPTIC TANK . ❑ CESSPOOL ❑ REPAIR 11 OTHER <br /> PERMANENT ❑ TEMPORARY NEW <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> F Type Construction <br /> Disposal Site ry <br /> I No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 L <br /> Where Certified <br /> Operator Name <br /> F ' Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19'- <br /> F <br /> 9'FSIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1.000 Sq.Ft. L <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. r <br /> F c <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f <br /> ordinances, state laws,and ru and regul tions of e n Joaquin Local Health District. <br /> F F t <br /> APPLICANTS SIGNATURE X <br /> 'r <br /> l <br /> C <br /> F11 <br /> I` FOR DEPARTMENT USE ONLY <br /> Fee Is Due-❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 37 ❑ July 1 R Reaeiv REMITd By uIy 31 <br /> F <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> f <br /> FEE C a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> h OTHER <br /> Receipt No pernnt No a s ,,� ts5ua at Mailed ,Delivered <br /> Re[e�vedby Ba a&w; Date i�< �s P „�, # r. ya � L� OCKTON.CASS201 <br /> Fv x1601E NA 9aa2t109 Y <br /> 4 <br /> APPLICANT—RETURN- ALL COPIES TO" tRON1ulETk'I:ALM PER ? . - . <br /> f <br /> .3tq <br /> .,.. • .. ....:..: .. .. .' 10.�..:il":�h j.l7^.1�,'i: -....,. .S - - � � W rte", ., L� <br />