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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1 APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) J <br /> 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 /> ,r Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildretii Lane <br /> a Owner T. R. McDonald Address Stockton Ca 95212 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 931`0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 308171 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date <br /> Please check Applicable Category (1-7) and Fill in the Required information h <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE � <br /> For July 1, June 30, 19 + �- Disposal Sites <br /> Description(Make/Yr., Color) t � 4 <br /> Serial No' CAL. License No. CAL. License Renewal No. (;\4 <br /> Capacity '` Gal., Weights & Measures No. w <br /> I <br /> Equipment Parking Address. <br /> 2. ❑ P6MPER 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 i R'S. or R.C.E. No. <br /> Test Location f Test Date/Time t { <br /> 4. ❑ SANITATION PERMIT ��6` � � �rt <br /> Job Address/Location <br /> Owner F <br /> Address: _ <br /> A SEPTIC TANK j❑ CESSPOOL LEACHING FI LD� I�SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT �O❑ TEMPORARYNEW { ❑ REPAIR 11OTHERS <br /> 5. 11CHEMICAL TOILETS For July 1, -June'30, 19 "_ ' <br /> Type Construction Disposal-Site 7;1" <br /> No. of Units Equipment Storage/Cleaning*Location(s) <br /> 6. ❑ PACI(AGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity `1�^ a_ No. Units Served <br /> 7. E],-LAUNDRY For July 1, -June 30, 19 f <br /> SIZE: t❑ Less Than 1,000,Sq. Ft., F-1More Than 1,000 Sq. Ft, <br /> El DRY CLEANING, Chemicals Used/Amount/Mo, <br /> 4 <br /> 'I hereby certify-that I have prepared this application and that the work will be done in-accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg Ions of the Sa Joaquin Local Health District. ) <br /> �` i <br /> APPLICANT'S SIGNATURE X f i �_gV <br /> FOR DEPARTMENT USE ONLY I <br /> a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re eived By January 31 ❑ July 1 &Received By July 31 <br /> - <br /> FBISE EXPLANATION BILLING REMITTANCE REMIT <br /> DATE -DATE---- AMOUNT DUE CHECKED <br /> --- .__ EMITTED.R � <br /> ' = AMOUNT <br /> FEEall_ <br /> LESS <br /> PRORATION <br /> PLUS f <br /> PENALTY �f <br /> OTHER <br /> OTHER p.y <br /> Kahl <br /> Received by ; Date Receipt No. Permit No. Issuance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 II <br /> a <br />