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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION "w <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is h r@by made to carry n business in the jurisdictional area of the San Joaqu�in Local Health District <br /> ,Business Name (DBA) ¢ua�ity Control. Inspectioon, I%i:lress 1295 N. Emerald Ave. Modesto,Ca. <br /> z Owner Sycamore Development Co. _ Address <br /> a 5720 Shattuck Ave. , Oakland, Ca.J Firm Partners, Addresses and Telephone Numbers ( 415 ) 655-3299 <br /> a. Business Telephone No. (209) 527-4940 / 466-8378 Emergency Telephone No. ( 209)527-4940 <br /> Contractor Licence No. N/A - Engineering-Testing- Inspection Firm <br /> �Applicants Name (Print) Q-C-I- by JESS WRY Title Engineer/-111P10yW7/28/88 <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) <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 StoredI <br /> 3. ElPERCOLATION TEST (HEMPSTEAD COURT SUBDIVISION) SU-87-21 `e r`� O CW U( <br /> R.S. or R.C.E. Name Quality Control Inspection R.S. or R.C.E. No. <br /> Test Location See Map Test Date/Time Will Call 7/88 to 8/5/88 <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) <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. <br /> I hereby ertify that I haue prepar this application and that the work will be done in accordance with San Joaquin County <br /> ordinanc , state laws, and rules a regul tidns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> Jless Wry, P.E. <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DAT EMITTED OL AMOUNT <br /> FEE d 't4-ir! <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER IV <br /> OTHER <br /> 7- ,290 Al <br /> Recei d 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 />