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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppucalion <br /> APPLICATION \\ <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby made carry n"siness in <br /> / hjuiquin Loca�eal Di tict <br /> r <br /> r <br /> Address <br /> y Business Name (DBA) �+ <br /> aOwner I' Address <br /> Firm Partners, Addresses and Tele g one Numbers Emergency Telephone No. <br /> a Business Telephone No. L� <br /> 4 <br /> Contractor Licence No. . Date <br /> L Applicants Name (Print) 1 Title <br /> 1 <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) CAL. License Renewal No. <br /> Serial Na. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> I <br /> Equipment Parking Address 1+ <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.G.E. No. 1 <br /> R.S. or R.C.E. Name l <br /> TesE cation � Test Date/Time <br /> 4.A SANITATION PERMIT f� �4 Off <br /> Job Addre LocationZM <br /> t <br /> 0 <br /> Owner Address ; <br /> ❑ CESSPOOL 19 LEACHING FIELD 13 SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ SEPTIC TANK � OTHER ' <br /> PERMANENT ❑ TEMPORARY : ❑ NEW REPAIR 506+417 r— �� �►T'�k>Eti���. <br /> 5. 13 CHEMICAL TOILETS For July 1, -`'June 30, 19 / a IlCiVA-9- +� <br /> Type Construction <br /> 11 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locaiion(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 F <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> I Plant Capacity i 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 /> ci <br /> i F <br /> fi <br /> pared this application and that the work will be done in accordance with San Joaquin County <br /> 1 hereby certify that I have prep P , <br /> ordinances, state laws, an les and re ation =Sa uin Local Health District. <br /> ` APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUB: ❑ ANNUALLY. ❑ PERLUNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivendBy lTuly 31 <br /> BILLING .REMITTANCE $ AMOUNT DUE - CHECKED <br /> " BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> k c <br /> FEE <br /> LESS <br /> PRORATION !1 <br /> PLUS V <br /> PENALTY <br /> OTHER <br /> OTHER <br /> y �l m Permit No. I su e D Mailed Delivered ,f <br /> eceipt No. _ AMO craricToN.CA 95201 <br />