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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) SEP?AGE <br />s"ENVIRONMENTAL HEALTH PERMIT <br />4 LIQUID WASTE <br />Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br />m Business Name (DBA) Santos Ranch Unit #5 Address P-0- Box 134 Tracy. CA. <br />i Owner Emily SantosAddress P.O. Box 134 Tracy CA <br />Firm Partners, Addresses and Telephone Numbers 835-7284 <br />'n Business Telephone No. Emergency Telephone No. <br />a <br />Contractor Licence No, <br />Applicants Name(Print) W. Dave Olmstead Title Pres. Date 3/28/84 <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 <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />Gal., Weights & Measures No. <br />No. of Chemical Toilets Stored <br />3. 7❑ PERCOLATION TEST <br />R.S. or R.C.E. Name J. H. Kleinfelder R.S. or R.C.E. No. <br />Test Location Santos Ranch iini t $5 Test Date/Time-419 1 <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br />S. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />Disposal Site <br />No. of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name _ <br />Plant Location — <br />Plant Capacity — <br />7. ❑ LAUNDRY For July 1, - June 30, 19 <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />No. Units Served <br />I hereby certify that I have <br />ordinances, state laws, ano; <br />APPLICANT'S SIGNATURE X <br />❑ PACKAGE PLANT <br />❑ OTHER <br />Where Certified <br />nd that the work will be done in accordance with San Joaquin County <br />San Joaquin Local Health District. <br />FOR DEPARTMENT USE ONLY <br />Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION BILLING REMITTAN <br />$ <br />AMOUNTDUE <br />CHECKED <br />DATE DA <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />IV Al' <br />PRORATION <br />PLUS <br />PENALTY <br />/ <br />OTHER <br />OTHER <br />t z1/H`a-\\�-t1 <br />Received y Dele Receipt No. Permit No. Issuance Date Mailed Delivered <br />Aee, ,e.u. err„eu A„ r..e,re m. cumen....VA, uew, ru eeeu,rr,rcomree .An. r uvn mu eve e n e,.. enm ernrrrnu nA ocom <br />