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- Applications Will Be Processed When Submitlc;. ry I ompleted. be cure 10 aigh Id'e A'ppoldudlL <br /> AF' ^1 TION <br /> (For Non-Transfer ..vocable, and Suspendable) SEPTAGE <br /> ENVIRONMI AL HEALTH PERMIT <br /> 'g WASTE <br /> ^ Application is hereby made to carry on business in 4ictional area of the San Joaquin Local Health District <br />/r Business Name (DBA) Los Ranchos Country E' Address 376 <br /> Towner Ormonde.etal. Ab, ^ Bnx Rnq,Tran .,calif <br /> Firm Partners,Addresses and Telephone Numbers 209/835-4949 <br /> iBusiness Telephone No. Emergency Telephone No. 2091835-0758 <br /> Contractor Licence No. <br /> Applicants Name(Print) —n—Ur—monde Title _partner Date 11 /"7n/81 <br /> Please check AppYnble 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 Gel.,Weights d Measures No. <br /> Equipment Parking Address <br /> 2 ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> oI Chemical Toilets Stored <br /> 3 PERCOLATION TEST <br /> . .orR.C.E.Name Micheal Frwin R.S.or R.C.E.No. R.C.E. #18625 <br /> Test Location Test Date/Trm2e 10-11-83 <br /> •. ❑ 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: <br /> 0, 19 SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ NING.Chemicals Used/Amount/Mo. <br /> Rlsu manRNa6M � teslenalura rieslMfoRawm9."Ieer[Wfhatfniheperfc,m3neeofLhewe:kfCrWhlchthlrpermltisbsued,Ishtll notEmployelrypMtal <br /> Qrhtreetw,a �r0vul wgen c car , 'S comper sArion 13y.�s of Cali:o-::ia. <br /> Nrira et wbrdanlls0"Ing " /an c"n"f:.U: a� tape <br /> ampmy pwau s svl jed to wort nu is n faNs of GLNa.J�' " '0` leen ty that n the perforW' cmordance <br /> ork for which this permit b Issued,I thsti <br /> - I hereby certify that I hav red this sepplian at the w will be with San Joaquin County <br /> ordinances, state laws,an and reguln Joaquin L I Health <br /> APPLICANTS SIGNATURE 1&4 10 <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑PER UNIT 11 PER srrE ❑ EACH ❑ January 1 1 Received By January 31 ❑ July I e Received By July 31— <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE = AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMWNT <br /> FEE c)- <br /> LESS <br /> LESS <br /> PRORATION <br /> PPEEUS <br /> NNALTY12-`1 <br /> OTHER <br /> OTHER <br /> Received W Dow Receipt No. Permit No. Issuarros Dau Mailed Del a, <br /> APPLICANT—RETURN ALL COPIES TO.. ENVIRONMENTAL HEALTH PERMR/SERYICES 1601 L W12ELTON AVG,P.O.B.7009 STOCIITOK CA 9541101 <br />