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4 <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i � (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District M1 <br /> H Business Name (DBA) McDonald Se Tank Service Address Hi 1 dr th Lane <br /> a Owner Address $d[lle <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 9 1-0497Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 308171 <br /> I, LApplicants Name (Print) _ Title Owner Date <br /> Please check Applicable Category (1-7) and-Fill in the Required Information I <br /> 1. ❑••PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH,VEHI_CLE) <br /> -For July 1, Ju a 30, 19 ` Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. *�. E CAL Licc�se Renewal No. - <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 11,— June 30, 19 <br /> No. of Vehicles'S`tored <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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Add /L r <br /> Owner. �s Address C <br /> SEPTIC TANK © CESSPOOL {0°LEACHING FIELD SEEPAGE PIT ❑ PACKAG PLANT G <br /> ❑ PERMANENT ❑ TEMPORARY tX NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS-For July 1;"'"'"Juee 367119' <br /> Type Construction $iF � -- � Di posal Site <br /> No. of U nits Equipment Storage/Cleaning Location(s) '" ^` <br /> 6./tD PACKAGE TREATMENT PLANT For July 1, -June 30, 19� . <br /> Operator Name <br /> N Where Certified <br /> Plant Location I C <br /> Plant Capacity No. Units Served O <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 IJsd/AmounVMo. a <br /> c <br /> 34 . <br /> I 'hereby Fcertify that?I have.prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r`,ulley <br /> �VTs anis regulations of the San Joaquin LocafHealth District. <br /> APPLICANT'S SIGNATURE X 1 � � - — - <br /> 461 <br /> k FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Q ANNUALLY r❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> `�- <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEELA <br /> r t+ g <br /> LESS s47 �- <br /> PRORATION _ <br /> PLUS ( 4 <br /> PENALTY - <br /> OTHER <br /> I OTHER 4 - <br /> E 9 . <br /> Received byDate Receipt No. Permit No. suance Date tailed Delivered <br /> . . <br /> APPLICANT-RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT!_SERVICES ... -1601 E.HAZELTON AYE.,P.D.Bo:2009, STOCKTON,CA 95201 <br />