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_ - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION J <br /> (For Non-Transferable, Revocable,and Suspendabie) <br /> t ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) McDonald d_Septi c Tank Berri Ce Address . . 46 <br /> 45 jai 1 dreth Lane <br />'i Owner T. R. 1�7CDonald ._ Address same <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 114 <br /> a. Business Telephone No. A-41 —x447 Emergency Telephone No. .957-4027 <br /> Contractor Licence No._30 171 4 <br /> Applicants Name (Print) 71 - $ Title Owner Date 1 <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �} 14 <br /> For July 1, June 30, 19 i Disposal Sites W <br /> Description(Make/Yr., Color) d <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. f <br /> Equipment Parking Address <br /> i 2. ❑ PUMPER YARD - +� <br /> For July 1, June 30, 19" i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored i <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 t91 <br /> i <br /> Job Address/Coca n t <br />[ Owner Address i <br /> ❑ SEPTIC TANK ❑ CESSP L ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> f ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 / \ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5. ❑ 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., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �j <br /> I hereby.certify that I have prepared this application and that the work will be done in accordance with n o quij' 1ty <br /> ordinances, state laws, and r an regulati f the San Joa Jin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> t FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 & c 'v d January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> �IAYITEO BASE EXPLANATION + AMOUNTDUE CHECKED <br /> DATE. DATEAMOUNT �5 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY ) <br /> OTHER <br /> Nx <br /> 1 <br /> OTHER <br /> b 4 Ig I jib <br /> Received by Date Receipt No, - Permit No. PssuancDale Mailed Delivered <br /> f. - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Boal OS ,/STQC�� CF971 <br />