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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, 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 Local Health District <br /> H Business Name (DBA), MC DONALD SEPTIC TANK SERVICE Address 4645 HILDRETH. LANE <br /> a Owner T. R. MC DONALD . Address SAME <br /> JFirm Partners, Addresses and Telephone Numbers <br /> aTelephone No. 957-4027 <br /> Business Telephone No. 931-0497 Emergency <br /> Contractor Licence No. 308171 1 <br /> li LApplicants Name (Print) T. R. MC DONALD Title OWNER Date ^h <br /> Please check Applicable Category (1-7)and Fill in the Required Information. .r <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. Lic�'sse Renewal No. - <br /> r <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD `a <br /> For July 1, June 30, 19 t � <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name - <br /> R.S. or <br /> Test Location ! * Test Date/Time <br /> 4. ❑ SANITATION PERMIT A <br /> Job Address/L cation i <br /> Owner 4 <br /> SEPTIC TANK CESSPOOL LEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANTI <br /> PERMANENT ❑ TEMPORARY NEW if 13 REPAIR ❑ OTHER <br /> 1 S. 11 CHEMICAL TOILETS For July 1, -Jun 30; 19 cwt <br /> Type Construction _ DisposalzSite # <br /> No, of Units Equipment Storage/Clea ng,Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1. _June 30, 19 <br /> Operator Name Where Certified <br /> I Plant Location , �Ar- <br /> Plant Capacity <br /> -- - No lJriI s Served 1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> G SIZE: ❑ Less Than 1,000 Sq. Ft., ID More Than 1,000 Sq. Ft, f <br /> w ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j ! hereby certify that I have prepared this application and thatrthe,r ork will be done in accordance with San Joaquin Country <br /> ordinances, state laws, a d r and regulauQns of the SaneJo in Local Health Disfricly-0 <br /> APPLICANT'S SIGNATURE X#/ , <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ AN 'LLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> } REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ��p <br /> LESS ~w r <br /> PRORATION <br /> PLUS - <br /> PENALTY _ <br /> OTHER <br /> f OTHER <br /> c <br /> . Received by Date Receipt No. - Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES-TO; ENVIRONMENTAL HEALTH PERMITIS VICES 1601 E.HAZ LT N AY ,P.O.Box 2009 STOCKT�" CP195 0 i <br /> �- � _ �n1-i5slo�l 5>rar�-�e�.�r <br />