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Applications Will ue Processed When auhmllted Yropeffy sotfiplelea. Ise ouie 1u OIQII L,Ih H jvu�hdwli. /! <br /> APPLICATION C K <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> H '1 E I N FF LIQUID WASTE <br /> Applicati n is h m de to on usin In unsdictional area of the San Joaquin Local Health District <br /> �osalcosD `�unrysa�e P,O. Box 805,Trac Calif. <br /> Business Name (DBA) Address y <br /> �Owner Ormone,etal. Address P•O.Box 805,Tracy,Calif. 95376 <br /> Firm Partners,Addresses and Telephone Numbers 209/835-4949 <br /> s. Business Telephone No. Emergency Telephone No.2 0 9/8 3 5-0 7 5 8 <br /> j Contractor Licence No. <br /> L Applicants Name(Print) Gi-PIrPn OrmnndP Titlei a,"+n Pr Date 11/30/83 <br /> Please clack 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 /> Equipment Parking Address <br /> 2 ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> 01 Chemical Toilets Stored <br /> PERCOLATION TEST <br /> . -or R.C.ENam Mir•haP1 F.rwin _ R.S.orR.GENo. R.C.E . #18625 <br /> Test Location ,, � � p�� TF Wing <br /> DateoRme 10-11-83 <br /> 4. ❑ SANITATION PERMIT (_0 S w✓Le.v w� T S- D a �3 <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 /> ❑,p{,iy-CLEANING. Chemicals Used/A nVMo. <br /> bI s11 F1anaYr Ba to sed sQerle'a syn.run sthsionowing:^Iee"Uyfhaf in theperformsnceof L9ewe.ictuahidtthlapermltb6wedlthallnottm Io e <br /> Cw+tlaetsr's oecomesuattnotmrk an' tmnpensahonir.:salcat7:o-r.i:I.' D Y rVYVVM <br /> Mr:11p er n+a-conheCtlnO •m c.Y.if:as ti�� /sib <br /> aihly pelsarts wtyect to worAman s tl n Taus of ca4k:.J�.' e"mt �l certify that in the pertarnunce of Ota work for which fNs permH Is Issued,I than <br /> 1 hereby certify that I hav p red this ap I 9thatwork will ne in accordance with San Joaquin County <br /> ordinances,state la and regulat' an Local 1 District . <br /> APPLICANTS SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNuALLY ❑PER UNIT ❑ PER srrE ❑ EACH ❑ Januuy 1 a Received By January 31• ❑July I&Recnved By Juy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE If AMOUNTOUE CHECKED <br /> ... . . - DATE DATE REMITTED AMOLINT <br /> FEE <br /> I 5 g aS <br /> LESS <br /> PLUS PRORATION <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -vn la g3 <br /> Received by Duke Receipt No. Pumd No. Isawnce Onto Mailed DMirarad <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL NEALT"PERMIT/SERVICES ISI E W12ELTON AVE,P.O.S=2DW STOCKTON,CA ISM <br />