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Applications Will Be Processed When Submitted Properly Completed. Be Sure o Ign e p <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE ff <br /> ENVIRONMENTAL HEALTH PERMIT', r <br /> LIQUID WASTE� <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> 4645 Hildreth <br /> ..Business Name (DBA) T . R . . MC3]_ BSAle t <br /> x Owner T. R. MCDonald Address <br /> a 1 <br /> S Firm Partners, Addresses and Telephone Numbers ��7_ ,02 <br /> A. Business Telephone No. 9310497 Emergency Telephone No.— <br /> i Contractor Licence No. T . R. McDonald � 0 i <br /> 4 jj Title Date <br /> �Applicants Name (Print))- �. I <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMpIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June..30, <br /> I Disposal Sites <br /> 19 ��k� �` � � <br /> Description(Make/Yr., Color). - � <br /> , <br /> CAL License No. CAL. License Renewal No. <br /> Serial No. ti <br /> Capacity Gal., Weigh�t�&Measures No. 4!f <br /> Equipment Parking Address <br /> 4r ^ t� <br /> (✓ r <br /> 2. ❑ PUMPER YARD 0 x .�oj <br /> For July 1, June 30,19 * ' <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> • R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test D to/Time ' <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner ,• Address ) ; .. <br /> SERMANENT EPTIC TANK CESSPOOL LEACHI G`FIELD ❑SEEPAGE PIT <br /> PACKAGEPLANT 1 t <br /> ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> ❑ � 0 <br /> 5. ❑ CHEMICAL TOILETS- For July 1, -June 30, 19 a `� <br /> al Site + � <br /> Type Construction Dispos.ti <br /> NEquipment StoragelCleaning Location(s) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT_For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name f <br /> k Plant Locationrs <br /> _ 1%Ic No,jUnits Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY'For July 1, -June 30, 19 <br /> !!! SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. - <br /> ... <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 1 J 2Y <br /> I hereby certify that I have prepared this athe <br /> application and that work will be done in accordance with San Joaquin County <br /> p <br /> p ordinances, state laws, and rules and regula ' ns f the San Joaquin Loc I Health District. <br /> 'I 'APPLICANT'S SIGNATURE k - <br /> • ',, ,ter„ . <br /> r FOR DEPARTMENT USE ONLY <br /> By <br /> Fee Is Due:�❑ ANNUALLY ❑ PER UNIT 01111 SITE ❑ FA CH ❑ January 1 &Received By January 31 ❑July 1 &Received 31 <br /> ' BILLING R E $ AMOUNTOLE CHECKED <br /> Y BASE EXPLANATION DATE REMITTED; AMOUNT <br /> FEE <br /> LESS <br /> I PRORATION <br /> PLUS <br /> I. PENALTY <br /> OTHER } <br /> OTHER <br /> OA <br /> {� Received by <br /> #Date Receipt N. Permit N. Issuance Date Mailed Deliv, ed <br /> �� ;APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMITISERVICES 1607 E.HAZELTON AVE.,P.O:Box 2009 STO TON,G 4520 <br />