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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> A%. n. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> a <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) MgDonald Septic & Backhoe t Andress 464.5 -'Hi:ldreth' Lane <br /> zOwner T. R. .McDonald - Address - Same <br /> J Firm Partners, Addresses and Telephone Numbers 431 OZQ 7 <br /> CL Business Telephone No. Q.31_Q 497: Emergency Telephone No. <br /> Contractor Licence No. -- <br /> Applicants Name (Print) T R-,,MnDon.al.d 'Title- QsATnerY Date <br /> '4 <br /> Please check Applicable Category (1-7)and Fill in the Required Information - }. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Y 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 <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 Address/Location— ,1�� OT"7- <br /> 0050--k I <br /> Owner RdgBC—Aw N �fJf �y Address r 'e <br /> SEPTIC TANK E] Je:�CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT V� <br /> ❑ PERMANENT ❑ TEMPORARY >'NEW ❑ REPAIR ❑ OTHER y,)t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 !i <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 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,'19. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,,�- 13P More Than 1,000 Sq. Ft.^ _ ~rt <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. -- - "- •' <br /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin CoOrlty- <br /> ordinances, state laws, and rules and regu ions of the San Joaquin Local Health District. t <br /> e <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 /> BILLING REMITTANCE �$ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED. .. AMOUNT _ <br /> FEE <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> !L ell <br /> -i <br /> OTHER <br /> - Received by Date Receipt No. Permit No. Issua a Dale _ Mailed Delivered j <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005 STOCKTON,CA'95201 <br />