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Ayyuwumia mu oe rracesseu "nen auomuteu rrupeny t omptetea. Ice aure to sign the APPIlud"0111. <br /> APPLICATION <br /> (1,i Non-Transferable,Revocable,and Suspendablt. SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i�ferepy ma a to carry n busine in the jurisdictional area of the©Joaquin Local Healtt�.Distnct <br /> ,�' (!o fYx@ .dirk 7,C`! pCitC.r- <br /> F Business Name (D$II)�r Address <br /> i Owner ��— `O "l Address <br /> Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone No. -�6 dJ/ O.S Emergency Telephone No. <br /> Contractor Licence No. z 2- - 4 <br /> �Applicants Name (Print) .! ZYZY A. _Title Date /C —9—.Pd <br /> ' <br /> Please check Applicable Category (1-7) and Fill in the Required InformationV <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) - -- <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity - _ Gal.,Weights'&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name - R.S.or R.C.E. No. <br /> Test cation I i Test Date/Time <br /> 4. <br /> Test <br /> PERMIT r <br /> Job Addres cation <br /> %1� <br /> Ow r _ Address - 7 l <br /> �$E_PTIC TAN ❑ CESSPOOL E ACHING FIELD ,SEEP GE PIT PAORAdE PLANT <br /> [? PERMANENT ❑ TEMPORARYEW <br /> �a ❑ REPAIR OTHER (n <br /> 5. ❑ CHEMICAL TOILETS FcS JyIu`If-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units _ _i_ - Equipmet Storage/Cleaning Locationts) <br /> 6. 11PACKAGE TREATME*"LANT—+ror-dW 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location A <br /> Plant Capacity 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 /> r , <br /> I hereby certify that I have prepared this application and that the work will be done i accordance with San Joaquin County <br /> ordinances, state laws, and r s and regulati ns of the San Joaquin Local Heal h D1 ict. - <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT U -NLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Anuary 1 &Received By January 31 ❑ July i 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING ANCE $ AMOUNT DUE CHECKED <br /> DATE PATE REMITTED AMOUNT <br /> FEE 5— '� L( S a <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER VY <br /> OTHER y <br /> v <br /> Received by Date Receipt No. Permit No. uance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1507 E.HAZELTON AVE.,P.O.Sol 2009 STOCKTON,CA 9S20t <br />