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-.. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S�PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) McDonald Septic Tank Serti.ce Address 4645 Hildreth Lane <br /> N same <br /> z Owner .T. R. McDonald Address <br /> a <br /> a.Firm Partners, Addresses and.Telephone Numbers <br /> aBusiness Telephone No-'931-0497 Emergency Telephone No. <br /> Contractor Licence No. 308171. <br /> � <br /> Applicants Name (Print)—T. R• McDonald Title 0 finer Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information ) <br /> t s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH;VEHICLE) � . <br /> For July 1, June 30, 19 Di posal Sites -,� td,t+ `+ ' <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Lic rsse Renewal Na. <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 Q <br /> No. of Chemical Toilets Stored + <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Y <br /> Test Location Test date/ ime <br /> 4. ❑ SANITATION PERMI _ <br /> Job Address/Location z <br /> Owner Address <br /> 'SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACK GE PLANT <br /> PERMANENT ❑ TEMPORARY 'V. NEW1�Y �+ �� ' �_ <br /> REPAIR ❑ OTHER <br /> 5. }}}❑ CHEMICAL TOILETS For July-1, -Jun 30619 � <br /> Type Construction Disposal Site <br /> No. of Units .1 Equipment storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLAN fFor July 1, -June 30, 19 <br /> Operator Name L - _ 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 5q. Ft.,N ❑ More Than 1,000 Sq. Ft. <br /> ' <br /> El DRY CLEANING,Chemicals Used/AmoUnt/MO. N'. <br /> 3 <br /> wAi <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J <br /> ordinances, state laws, and rules and regulation ,;o the San Joaquin Local Health District. <br /> s <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> }T <br /> Fee IS Due: 11 ANNUALLY) ' .❑,PER UNIT _� ❑ PER SITE'S ❑ EACH ❑ January 1 &Received.By January 31 E3July I &Received By July 31 <br /> � REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i,. DATE DATE REMITTED AMOUNT <br /> tFq8-> -4 HIS <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 5qla 126 <br /> i, <br /> Date Receipt No. Permit No, Iss nce Date Mailed Delivered <br /> Received by ✓ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boz 21109. STOCKTON,CA 95201 — <br />