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perly <br /> Applications Will tae Processed When SuAPPLICATION '�. <br /> A. SEPTAGE <br /> (For Nan-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> 4645 Hildretn Lane <br /> lication is hereby made to carry on b T Min S 2rrV1lC@ nalgarreeaeof5the San Joaquin Local Health District <br /> �D TACDonald Se tic same <br /> N Business Name (DBA) R. McDOnald Address <br /> a Owner 957-4027 <br /> u Firm Partners, Addresses 931-6497 Numbers <br /> Emergency Telephone No.— l <br /> a <br /> C6 Business Telephone No. 3��171 Owner Date <br /> Contractor Licence No. Title <br /> L applicants Name (Print) - McDonald <br /> and Fill in the Required Information <br /> Please check Applicable Category.(1-7) _ } <br /> ,- X� Disposal Sites <br /> y, ❑ PUMPERVEHICLE June PERMIT, <br /> lT R� ATiON (FOR EACH VEHICLE) <br /> For July 11CAL. Liccnse Renewal No. <br /> Description(Make/Yr.,Color)` <br /> CAL. License No. <br /> Serial No, Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> c� <br /> 2, ❑ PUMPER YARD ,w <br /> Far July 1,_ June:30,-,,19ti <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> : p <br /> 3, ❑ PERCOLATION TEST —P R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> g. ❑ SANITATION PERMIT r <br /> Job Address/Locatios ❑ PACKAGE PLANT <br /> f F <br /> Owner LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> i SEPTIC TANK CE 5 QLD ❑ REPAIR - <br /> ❑ TEMPORARY NEW <br /> PERMANENT1, _June 30, 19 <br /> 5, ❑ CHEMICAL TOILETS For July Disposal Site <br /> Type Construction } <br /> Equipment Storage/Cleaning Location(s). <br /> No. of Units <br /> (` y � � Where Certified <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, June 30, 19 <br /> Operator Name I <br /> Plant Locationj� No. Units Served <br /> plant Capacity <br /> T. ❑ LAUNDRY For July 1,-June 30, 19 j,()00 Sq. Ft. <br /> SIZE: 11 Less Than 1,000 Sq. Ft., € <br /> Than <br /> t <br /> ❑ DRY'CLEANING, Chemicals Used/Amount/Mo. � t <br /> ll be done in <br /> I hereby certify that I have prep and this <br /> ulatolnsaof the San Joaqu'work <br /> Lo al!Health District.accordance with <br /> aquin County <br /> tion and that the <br /> ordinances, state laws, and rules g <br /> APPLICANT'S SIGNATURE X <br /> k FOR DEPARTMENT USE ONLY <br /> Jul 31 <br /> ❑ r 1 �Received REMIT <br /> By January 31 � ❑ July 1 &Received By y <br /> ❑ PER SITE ❑ EACH' <br /> $ AMOUNT DUE CHECKED <br /> Fee IS Due: ❑ ANNUALLY <br /> PER UNIT -Januay BILLING REMITTANCE AMOUNT <br /> EMITTED <br /> I' BASE EXPLANATION DATE DATE R <br /> FEE <br /> y LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance Date ,Mailed De4ivered <br /> Permit No STOCKTON,CA 95201 <br /> Date Receipt No. �1601 E.HAZELTON AVE:,P.O.BOF 2009 <br /> `- Received by - ENVIRONMENTAL HEALTH PERMITISERVICES <br /> APPLICANT—RETURN'ALL COPIES TO: - <br />