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Applications vvm ce rroc—seo vvnen auomnteo rropeny t..ompieteo. oe au .,01911 t me..pNucauUn. <br /> r.. APPLICATION "Nor <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SE NAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r Application is hereby made to carry on busines in the j dsdictional area oft S Jo Lin L e h qi trict -� <br /> rn Business Name (DBA) Ernie s Septic Tank 6o. 1nC. Address • ' 19CX � YlOU1► Calif. 05240 <br /> Dwner Ernest Roberge Address Same <br /> irm Partners, Addresses and elephone Numbers <br /> aBusiness Telephone No. 38-5105 Emergency Telephone No. <br /> contractor Licence No. 32 22 <br /> Applicants Name (Print) IMIXI M Ernest Roberge Title President Date 2-1 <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 /> am 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 W <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. —� <br /> ,Test Location Test Date/Time _ ;5 Q <br /> 4. IN SANITATION PERMIT <br /> Job Address/Location Skinner Ranch 13115 N. Hiwy 99 Lodi , Calif. 95240 <br /> Owner Address <br /> r..❑ SEPTIC TANK ❑ CESSPOOL 12 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> EXPERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER .G <br /> 5. ❑ CHEMICAL TOILETS. Fiir:July 1,-June 30, 19 .0 <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/Filo. <br /> r, <br /> I hereby certify that I have prepared this application and that the work will be done in accoriddfffb-With-San Joaquin County <br /> ordinances,state laws,a rules and regu sof the San Joaquin 6c I He th District. <br /> r.APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janua ceived By January 31 ❑ July 1 8"Received By July 31 <br /> REMIT <br /> Yrs BILLING REMITTA $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> r.s LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> yr OTHER <br /> OTHER <br /> Received by Dateceipt No. Permit No. Issuance Date Mailed elivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Box 2009 STOCK ON,CA 95401 <br />