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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) SEPTAC <br /> ENVIRONMENTAL HEALTH PERMIT 9 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> v;Business Name (DBA) Address <br /> a Owner MAXIM iMM Address?4C1,CO _53C)IN E-2 RZZ A Ah M C-A �5��-����Td <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. __ _ Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) �6LAL._E F _ Title CIVIL lENCatNEEV Date--5Z.0 <br /> Please check Applicable Category (1-7) and Fill In the Required Information /�� II�" 2a9 <br /> 84 <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4IS MKMPLAZA <br /> For July 1, June 30, 19 Disposal Sites Lobt)CA. 9Sz4-<_'� 3(o8- 4-(S9 <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 1 , <br /> No of Chemical Toilets Stored p Y <br /> 3. *t.PERCOLATION TEST `� ll3 MATt?I��t FLAZA Ms-9 j— <br /> R.S. or R.C.E. Name WACI:E E C-uV7115 t OUI,C^ /524'O *A IiIiiiQ R.C.E. No. Sa - (7 <br /> Test Locatiori I90r) ':in1 Ac-^MRN GA 9Test Date/Time IN 114- r PL-IL, -V�CTABLAS,14 hA7E AWn MI IAIE I� <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _ - Disposal Site _ (� <br /> No of Units Equipment Storage/Cleaning Location(s) _ f' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -_ Where Certified <br /> Plant Location <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. IIIJJJ��� <br /> Home owner or lircensedage- err;-I-+,(-r-:- thp to!tav,fr.r rf" "': "+ mr#er!i?^ro of the work.for whirh!his permit is issued,l shalt not ploy any person <br /> in sech manner ...!o C.cco:: 'anti to pi : „ .. ,r(pefISB'r1 n la,._ ait . <br /> Contractor's hiring or subcontracting sigrawre card':e. me -*fiowmg. , certify thatln the performance of the work fer which this permit is issued,I shall <br /> employ r,otkiaan's wpapensation laws of t aiitornia. <br /> I hereby certify that I have prepared this.application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and <br /> /rul sand regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X :L� — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /�//�� <br /> (� 4�J AMOUNT <br /> FEE -no �` �O '�tI �' Zv -L� •0� - <br /> LESS <br /> PRORATION <br /> PLUS — - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rY1k_ -Z -9/1, 3" <br /> Received by Date —receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />