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Appllcatlon11 Will ue Ye�Oeesa'ej7w4>•11ou6rhmi'u rrupllny "- wk1 J Ju. u6 ems ... ��9'• ..rr••L`^• <br /> APPLICATION <br /> (For Non-Translerbble,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin LOGSI Health District <br /> rBusinessNa�1Ie (DBA1_Los RanChOG Country Estate Address P.O. BOX 805 <br />�owr�T UYIttOn e,Eta1. Address P.O.Box 805 Arany Oa95376 <br /> 0 Firm Partners. Addresses and Telephone Numbers 209/835-4949 <br /> i Business Telephone No. <br /> Emergency Telephone No. 209/835-0758 <br /> Contractor Licence No. 11/30/8 3 <br /> Applicants Name (Print) Steven OrMQn,9 e Title Date <br /> please theca 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 <br /> - -Description(Make/Yr.,Color) <br /> Serial No. CAL License No. CAL License Renewal No. <br /> Capacity Gal.,Weights b Measures No. <br /> Equipment Parking Address <br /> 2 ❑ PUMPER YARD <br /> For July 1 June 30,19 <br /> No.of Vehicles Stored <br /> of Chemical Toilets Stored <br /> PERCOLATION TEST <br /> orR.C.EName Mi hael ET-Win R.S.orR.C.ENo. R.C.E . #18625 <br /> Test Location jest Date/Time 1 1—1 n—R 4 <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 EANING.Chemicals Used/Amount/Mo. <br /> M or�wd apent'e synetu» }testas <br /> W a1dRh11f do 10 became sublect to N-0 m 's craa'.M. jpo 13- <br /> W., �a tishat nlhlperformarceof Ltie we:kferwhich thlspermNlsUwed,Ishdlnotunpl0yanypsRgl <br /> Mrip er wb coneroci no tune rmt:aa ore latie wng; 1 certify that n thef <br /> perdrra2l=of Ota work for whleh INS <br /> _ . . Y p11roona 11ahjed fd workman's an lava of LAI::.,k_' p9rmK U Is11uad,I shall <br /> 1 hereby certify that I h pared this a p' ti and tha the work will beKisop <br /> cordance with San Joaquin County <br /> ordinances, state laws, and regul o the San Jo uin Local Heal <br /> APPLICANTS SIGNATUA <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dur. ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ Janiwy 1 a Received By January 71 ❑J01y/IS Remve0 91'AAV 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNTOUE CHECKED <br /> .y. DATE DATE REMITTED AMOUNT <br /> FEE �{ a•S 13 S 325° <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ (�,, <br /> OTHER (�VL1-I—I.�V <br /> OTHER <br /> --M �a oL 13 <br /> ReCo"d sy Dab Recaipl M. Ped No. I>.uance Date Makol Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL Hilui PERMIT/SERVICES 1111011 G W1gLTON AVE.,P.O.ser 2009 STOCKTOM CA$5201 <br />