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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 /> 1�\ 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 /> ,n Business Name (DBA) cp Address 4645 111 dreth I ane <br /> z Owner_ — CDona1 d Address 95212> <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> $ Business Telephone No. 931-0497 Emergency Telephone No. 957- �Z7 <br /> Contractor Licence No. 308171 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date <br /> Please check 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 /> SCAL. Licc Ise Renewal No. <br /> Serial No. CAL. License 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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST aw <br /> t R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> L Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT' <br /> Job Address/Location, <br /> kner <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ANEW EPAIR ❑ OTHER <br /> t 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 /> k Where Certified <br /> Operator Name <br /> Plant Location - <br /> ' Plant Capacity T No. Un s Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 _ _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 12000 Sq.Ft. T <br /> ( ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r. s <br /> I hereby certify that I have prepared this applica ' n an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and-rules d regulations f t e Sa Joaquin Local Hea h Dis <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 /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> (, DATE DATE REMITTED AMOUNT <br /> C <br /> FEE <br /> I LESS I <br /> PRORATION <br /> k „ PLUS <br /> PENALTY <br /> t OTHER <br /> OTHER <br /> - <br /> Receipt No, Permit No. Issuance Date Mailed Delivered <br /> Received by Date <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 85201 <br />