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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> f: (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG <br /> LIQUID WASTE <br /> i <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local-Health District i <br /> ,n Business Name (DBA)- MC DONALD SEPTIC TANK SERVICE Address 4645 HILDRETH LANE <br /> SAME <br /> Owner T. R. MC DONALD Address <br /> 1 <br /> 0 Firm Partners, Addresses and Telephone Numbers 957-4027 <br /> a qR1-0497 Emergency Telephone No. <br /> E Business Telephone No. — - OWNER [� <br /> }Contractor Licence No. D 30$171 q <br /> LApplicants Name (Print) T. R. MC DONALD Title <br /> OWNER Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information r n <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) v l t <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) - i <br /> CRL. Licc sse Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gai.,Weights & Measures No. r <br /> Equipment Parking Address j <br /> 2. ❑ PUMPER YARD I <br /> I <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. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addresss//L.ocatio <br /> Owner Address ❑ PACKAGE PLANT �) <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br /> ❑ PE=RMANENT - E] TEMPORARY 11NEW 13 REPAIR <br /> ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 g ' <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 (A <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units 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. FL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> I hereby certify that I have prepared this application ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule and regulatio o he San Joaquin Lo al H th District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Recewed <br /> By July 31 <br /> REMI <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ' FEE y <br /> = LESS <br /> PRORAMN <br /> PLUS rJ�(J� ' I l Q U C pW. <br /> PENALTY <br /> .OTHER <br /> OTHER 4 <br /> � dd� � � L <br /> Received by "_7 Date Receipt No. Permit No. Issuatice Da§e Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E,HAZELTON AVE.,P. x OCKTON, 1 <br />