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- Applications Will Be Process`ed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ^c '+ (For Non-Transferable, Revocable,and Suspendable) <br /> y ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> is <br /> ,F Business Name (DBA) MC DONALD SEPTIC TANK SERVICE Address 4645 HILDRETH LANE <br /> z Owner _ �' - T. R. MC DONALD_ __ Address SAME <br /> a <br /> ,Firm Partners, Addresses and Telephone Numbers <br /> Q. <br /> Business Telephone No. 931--0497 __ Emergency Telephone No. 957-4027 <br /> Contractor Licence No.._ 308171. - <br /> < Applicants <br /> 08171. - <br /> Applicants Name (Print) T. R. MC DONALD Title OWNER Date CP <br /> i Please check Applicable Category (1-7)and Fill in the Required Information ) <br /> 1. ❑ PUMPER VEHICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) Sr4k [► <br /> _ Dis osak Sit <br /> est f � <br /> For July 1, June 30, 19 -;. ~ a' p -- <br /> Description(Make/Yr., Color) <br /> _Serial No.. .. CAL-..License No. CAI.. Licc ise Renewal No. <br /> Capacity�k T Gal., Weights &measuresNo. 0 tk- — # `` <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD ) <br /> For July 1, June 30, 19 ° ` <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored Ii. <br /> 4 3. ❑ PERCOLATION TEST <br /> I R.S. or R.C.E. Name R-97 or R:C.E. No. <br /> Test Location " Test D'te/Time <br /> a <br /> 4. El SANITATION PERMIT <br /> Job Address/Location t/' <br /> caner `�� Address A 1 <br /> SEPTIC TA K CE55POOL LEACHING FIELD ❑ SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ,I NEW tot ❑ REPAIR ❑ OTHER C> <br /> 5. ❑ CHEMICAL TOILETS. For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> t No. of Units } Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT'.For July 1; June 30, 19 1 <br /> Operator Name } . .. "�� _ Where Certified <br /> Plant Location _ " <br /> Plant Capacity No. Units Served `^M-- <br /> r <br /> 7'.1-❑ 6;4UNDRYJFor July 1, -June 30, 19 <br /> 4 SIZE: ❑ Less Thari;1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEAN ING,,Chemicals Used/Amount/Mo.: <br /> p I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County" <br /> l ordinances, state laws, and rules and regula of the San Joa n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> - Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> p D <br /> FEE <br /> • LESS .�- ' r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> c <br /> OTHER <br /> OTHER <br /> - Received by Date Receipt No Permit No. Iss ante Date Mailed Deliliered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PE IT/SERVICES 1601 E HAZELTON AVE.,P.O.Box 2008, ST C T A 5 1 <br /> rertnt55 ion Ctra�c- c.�-f�rs�,�rPs�" r �I� I <br />