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Applications Will Be Processed When Submitted Properlycompieieu - <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) f SEPTAGE <br /> a. r, <br /> - <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br />, .. x+645 HILDRETH LANE { <br /> '`Application is hereby tSEP TIC TANK sSERVICE,dictionaAddresl area sthe San Joaquin local Health District <br /> MCD SAME <br /> m Business Name (DBA) T. R. MC DONALD Address <br /> +a Owner 957-x+027 <br /> a Emergency Telep <br /> Firm Partners, Addresses and Telephone Numbers hone No. <br /> 931-0497 f <br /> j a Business Telephone No. 30$171I <br /> Date <br /> Licence No. Title 0WHE <br /> Contractor i n <br /> �fIINNIt <br /> T <br /> Applicants Name (Print) <br /> T. R. MC DONALD <br /> Fill in the Required <br /> Please check Applicable Category (1-7) and Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` �# r <br /> For July 1, <br /> June 30, 19 � Disposal Sites. <br /> Description(Make/Yr., Color) CRL. License No. y CAL, Lic-:�se Renewal No. <br /> I Serial No. . <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,x9 '!`+ <br /> No. of Vehicles Stored x F <br /> � No. of Chemical Toilets Stored r �� <br /> i 3• ❑ PERCOLATION TESTI R.§. Or R.C.E.No. <br /> R.S.or R.C.E. Name -+ est DateIme t <br /> Test Location <br /> r 4 ❑ SANITATION PERMIT '. r <br /> Job Address L catio - --- Address," <br /> ` ❑ PACKAGE PLANT <br /> Rwner LEACFiINGJ,FIELD '❑ SEEPAGE PIT <br /> J` VKSEPTIC TANK ❑ CE55P0 �,* ❑ REPAIR y ❑ OTHER <br /> b ❑ TEMPORARY, NEW <br /> rr' PERMANENT ,R y r �K. <br /> 5. ❑ CHEMICAL TOILETS For.Lily i, -J ne 30, Disposal Site y <br /> Type Construction s t <br /> � �No, of Units `� EquipmentyStorage/Cleaning Location(s) <br /> ) � <br /> r <br /> ' .I g, ❑ PACKAGE TREATMENT'PLANT For July 1, -Jun'Ie 30, 19 t Where Certified <br /> ! operator Name ) ; <br /> +' Plant Location No. Units Served <br /> K <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1,-June 30, 19 <br /> ❑ Less Than 1,000 Sq.'Ft3 ❑ More Than 1 FOOb Sq, Ft. <br /> SIZE: eVJ, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> } r <br /> I hereby certify that I have prepared this aa tions <br /> and that the work will be done in accordance with San Joaquin County <br /> I rul guIations he an Joaquin Local Hea h District. <br /> ordinances, state laws, <br /> f > <br /> APPLICANT'S SIGNATURE X <br /> ..t <br /> f FOR DEPARTMENT USE ONLY <br /> REMIT <br /> Fee Is Due: C1 ANNUALLY [3 PER UNIT <br /> El PER SITE El EACH ❑ January 7 &Receive$By January 31AMOUaTJDUE �ReceiGHECKEDved By Y <br /> µ <br /> E BILLING REMITTANCE REMITTED AMOUNT <br /> BASE ' EXPLANATION DATE DATE <br /> FEE 5 bin <br /> LESS <br /> + A PRORATION <br /> _ PLUS <br /> 11 p ! S <br /> ' PENALTY <br /> OTHER r <br /> '. (h�rrvw.erJ hi G.►wL .�+v S /s� f � -Cf G.rGA, <br /> OTHER ti <br /> pf.rf t�ilf.oYi,. <br /> t..tEj ` Mailed d <br /> Permit No. 155uan a Da e <br /> Date - Receipt No O/&Ct_ - y64tE.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 <br /> r Received by EL <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />