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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. } <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I�. <br /> LIQUID WASTE <br /> Application!';4 reb made to car►p�pnpb sln ss in t jurisdictional area of the S oaquin cal Health District <br /> HBusiness Name (DBA) +� '� CIC-' Address � � I.Jm� "ej Aye <br /> '- Owner 1/I7 � �f C ' — Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. <br /> Emergency Teleph�,,ne No. <br /> Contractor Licence No. 2.9: t g <br /> � <br /> Applicants Name (Print) Title Date {l J <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Qa <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liocase Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ; <br /> 2. ❑ PUMPER YARD <br /> i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> if <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location I Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addres Location /UG?y F S o',7N1 *D AYE <br /> Owner �eoAM130 /�0)z7.0& Address <br /> -r <br /> Q <br /> 10 SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY IN NEW 0 REPAIR ❑ OTHER �I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 70 / <br /> /�AcF! iyeS I <br /> Type Construction II Disposal Site 200 c;,14 T4vk- 3 <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name i Where Certified qy <br /> J <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19' rt <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 11 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> . d . <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules`and regulations of th an Joaquin Local Health District. } <br /> APPLICANT'S SIGNATURE X <br /> ;3 <br /> y FOR DEPARTMENT USE,ONLY i <br /> Fee Is Due: ❑ ANNUALY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januaryll &Received B�anuary 31 ❑ July 1 &Received By July 31 <br /> � REMIT <br /> LESS <br /> I-BASErREMITTANCE $ AMOUNT DUE CHECKED <br /> DATE REMITTED q� AMOUNT <br /> FEE <br /> PROBATION �- 1 <br /> PLUSPENALTYOTHER <br /> OTHER 7-3 5 7� <br /> Receivetl by Date Receipt NO. Permit No. issuance Date Mailed Delivered <br /> i - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> JL ° <br />