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-Applications W511 Be Processed When Submitted Properly Completed, Be Sure To'Sig'n-The App ation. <br /> APPLICATION _ <br /> (For Non-Transferable, Revocable,and Suspendable) _.,� -~�M1 ' <br /> ENVIRONMENTAL,HEALTH PERMIT SEPTAGE .R <br /> LIQUID WASTE - -_ - .` °" <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District . <br /> ,,Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildreth <br /> 4owner T. R, McDonald Address 4645 Hildretb T.nnc- � 1 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. li9 ___ _ Emergency Telephone No. <br /> Contractor Licence No. _ 398 .71 <br /> L Applicants Name (Print) T_ R. McDonald Title Qymer _ 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 /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD F <br /> For July 1,. ,June 30,19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. -0 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. Q <br /> Test Location Test Date/Time �7 <br /> 4. ❑ SANITATION PERMIT /^ QI <br /> Job Address/Locat iO l <br /> Owner Address e—. ' <br /> SEPTIC TANK ❑ CESSPOOL, LEACHING FIELDSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 11TEMPORA"RY ANEW REPAIR ❑ OTHER �I <br /> 5. ❑ CHEMICAL TOILETS -For Juiy 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 /> Operator Name Where Certified <br /> Plant Location F <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE:_ ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. � k <br /> ❑ DRY CLEANING,Chemicals Used/Amount/neo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule7d reations of an Joaquin L cal alth District. <br /> t i <br /> APPLICANS:'S SIGNATURE X t <br /> FOR DEPARTMENT USE ONLY ° <br /> Fee IS Due:\- NtUALLY ElPER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juky 31 <br /> � +I - REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE 'REMITTED <br /> r AMOUNT <br /> FEE 14k 6fJ f/ <br /> LESS <br /> PRORAT;ON <br />,.# PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Issuanc Date Mailetl De1iv ed <br /> Received by 1 No r i o. <br /> _ AMICANT—RETUfiN-ALL-COPIES TO: ENYIR SAL HEALTH PERMITISERVICES <br /> 1601 E.HAl'ELTON AVE.,P.O.Bow 2009 STOC TON A 95291 <br />