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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Qi <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) ZI 14i ter& &F-r.1111's - Address - <br /> aOwner Address. <br /> Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. ,_ a-Emergency Telephone No. <br /> Contractor Licence No. _ 2 <br /> Applicants Name(Print) �+ � ~� TJtlIc Date 7 <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. - y <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. '` _._ CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TE5T '� <br /> R.S. or R;C.E. Name �.. I R+S`or R.C.E. No. <br /> Test Location )' Test Date/Time <br /> 4. A SANITATION PERMIT ��":1; •R <br /> Job Address/Location 97 ° <br /> Owner _T _ Address 571-7--2-7 C= l <br /> ❑ SEPTIC TANK El CESSPOOL `4 LEACHING FIELD' Off Off SEEPAGE PIT ❑ PACKAGE PLANT ) <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW REPAIR ❑ OTHER �• <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site s <br /> � a <br /> No. of Units Equipment Storage/Cleaning Location s) �s <br /> 6. ❑'PACKAGE TREATMENT PLANT For July 1, -june'30, 19 <br /> Operator Name -.-Wherq Certified <br /> Plant Location ( _ <br /> Plant Capacity # No. Units Served ~� `- <br /> 7. ❑ LAUNDRY , For July 1, -June 30, 19 7- <br /> SIZE: ❑ Less Than 1,000 Sq: Ft.,' ❑ More Than 1,000 Sq. Ft. � <br /> ❑ DRY C,•� �Il}� f��5etlr<If��fN $� ..� �y#i�eadl;�:`'tktzrtl�t�i�fnthc Grfar, � . "'� <br /> Da•tzj t :S t r A� �l}1PPlfa #P iillp'�cUinll�tl lilarlfz?u�spfC:#Nf4rni�,'" P tlancsOflhet+iorkforwh% hihrs�p�rmiliSi su d,lStaffncterzs la A' <br /> .�5.�f h!HnS RF �Nt?-aAt}1TNWttR 3t'nAtl+rO aar#ft'�a tit,^, 19ItU�l"i <br /> E la"PQl�Ation lays at t alifQrai ,, ; ri p s cyRerson <br /> ng t certify chat in the psrf(i!MInCe of the work for which this permit is issued,i shall <br /> I hereby certifylthat I have prepared this application an—Th%Tthe v'frVrk"'Will'be done in accordance with San.Joaquin County <br /> ordinances, state laws, and rules and regulations of the San JgNuin Local Health District. i <br /> APPLICANT'S SIGNATUREX 4 <br /> Zi <br /> ---------------- <br /> . . FOR I;EP.ARTMENT,USE.ONLY ' _ <br /> Fee Is Due: ❑ ANNALLY C! PER UNIT 11PER SITE C1EACH ❑ January &Rece ved By Januar t ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ ' REMIT <br /> BASE EXPLANATION AMpUNT DUE CHECKED <br /> F b ` DATE .DATE - R iTTED ) AMOUNT' - <br /> FEE <br /> PRORATION4-+.•..-.,.,a...o.«.:�.�-..eo.+-a-�:-- ----- -- •-^�-..",.�.. .... <br /> PLUS s � <br /> PENALTY <br /> OTHER ` �r•,t:.S a %. . <br /> 4 * <br /> OTHER - <br /> 7 'n Y <br /> Received by Date Receipt No. Permit No. suance Date Mailed peliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2409 STOC ON,CA 95201 <br /> 4 <br />