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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 7* APPLICATION �M� AW -Aili 92-77 <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> F <br /> Appl icat' �by.Made to carry on business i the jurisdictional area of theSan Joaquin Local Health District <br /> CG, n ineerin & carve >n 100 C Manteca <br /> h Business N m (DBA) g g Address Calla Dr.. <br /> a Owner -aiP cheel Address same <br /> Firm Partners, Addresses an4 T le hon Numbers <br /> aBusiness Telephone No. 2 P39 ? Emergency Telephone No. <br /> a Contractor Licence No. <br /> LApplicants Name(Print) Ralph N, Scheel Jr. Title Owner Date Apr. 13"-982 <br /> 8�2_� <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 Na. CAL. License Renewal No. <br /> t <br /> Capacity Gal., Weights & Measures No. v <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. TYPERCOLATION TEST <br /> R.eor R.C.E. Name Donald —R. Scheel "y" R.S.or R.C.E. No. RCE 3382? <br /> Test Location 12733 Van Wyk Lane , Ripon Test Date/Time <br /> 4. ❑ SANITATION PERMIT w + <br /> Job Address/Location ) <br /> Owner Address t <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 /> I b �II <br /> Type Construction IDisposal Site <br /> No. of Units If Equipment Storage/Cleaning Location(s) F [� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 1 Where Certified "V <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -f June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq.: Ft., ❑ Mare Th_an'1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r _K <br /> Hameowner orlicensed agent'ss;gnetureIrtiflesthefollowin Icertify that inthe Performance ofthe work for which thlSpermit Is116gol,I*hRilnot pmplftyAry, AQ, <br /> in such manner as to become stibject to workman's coinpensaEioil jaws of California." <br /> Contraempty trr'sio hiring or sub-contracting signature certifies the following: "I certify that in the perforMaRCC Of the work for Which til±s p'Prtltj[is lyt;uff ,1051. \ <br /> emgloy persons subN to a k n's coin rf t fi s �� <br /> f hereby certIry t is P cave pt�e �a"� t lWs 1� $fltf�r and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and r ulations of the an J aqui n ocal ealth District. <br /> i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By July 31 <br /> r REMIT <br /> L& - L_BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEa6o <br /> LESS <br /> PRORATION <br /> --RWS i 1t� ti <br /> PENAI TY„ - - <br /> OTHER i <br /> OTHER <br /> Wl L4 I3 2- I o 45 <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 95.201 <br />