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Applications Will BeRProcessed When Submitted'Properly Completed. Be SureTaWWI.' �a•'�"' - <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE "" 1S <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> an Business Name (DBA) <br /> McDonald tic Se Address <br /> i owner <br /> t-K. McDonald Address <br /> -- <br /> R. <br /> _ GJ Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> i a Business Telephone No. 931-0497a 308171 <br /> Contractor Licence No. Title Date <br /> Applicants Name (Print) T • R• McDonald <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> Il <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) CAL. License No. CAL. License Renewal No. <br /> I Serial No. <br /> � Gal.,Weights &Measures No. I , - <br /> Capacity <br /> Equipment Parking Address (� <br /> 2. ❑ PUMPER YARD + I f 1 <br /> For July 1, June 30, 19 I <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST <br /> R.S. or R.G.E. No. +, <br /> R.S. or R.C.E. Name. Test Date/Time + <br /> Test Location <br /> 4. ❑ SANITATION PERMIT j <br /> Job Address/Locati <br /> Address _ <br /> Owner -;❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ,SEEPAGE PIT ❑ OTHER " { <br /> 1 ❑ TEMPORARY NEW 4 • ❑ REPAIR i <br /> PERMANENT T <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 1Disposal Site w <br /> Type Construction <br /> ( No. of Units Equipment Storage/Cleaning Location(s) <br /> f 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ..r <br /> Where Certified <br /> Operator Name <br /> Plant Location ` <br /> s No. Units Served <br /> Plant Capacity .. <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 ( <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ; ❑ More Than 1,000 Sq. Ft. <br /> r <br /> ❑ DRY CLEANING,Chemicals Used/AmounVMo. <br /> k <br /> ih <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> with District. <br /> ordinances, state laws, and rules nd re ulations of the San Joaquin Local } <br /> 4 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT PER SITE EACH ❑ January l &Received By January 31 July 1 &Received By July 31 <br /> Fee:IS Due: ❑ ANNUALLY REMIT <br /> - - REMITTANCE $ AMOUNT DUE CHECKED <br /> BILLING :a <br /> BASE � EXPLANATION DATE PATE REMITTED AMOUNT <br /> I r <br /> 5 <br /> I <br /> FEE <br /> 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I .. <br /> OTHER - G <br /> fy Issuance Date Mailetl Deli <br /> ' Date - Receipt No. - Permit o. _ N,CA 01 <br /> Received 4y- .. - 1601 E.Hp,zELTON AVE,,P.O.Box 2009 _STO <br /> 'APPLICANT—RETURN ALL COPIES TO:• ENYI MENTAL HEALTH PERMIT/SERYIGES <br /> r <br />