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• Applications Will Be Processed When Submitted Properly Completes tse sure 1w <br /> APPLICATION �► <br /> v+ (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 6ddress <br /> Business-Name (DBA) <br /> za Owner <br /> T. R. MCDOnald Address <br /> 9 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. – <br /> 4027i <br /> K a Business Telephone No. 931-04 <br /> Contractor Licence No. 3 �� Title Date <br /> is Applicants Name (Print)—T. R <br /> [ Please check Applicable Category(1-7)and Fill in the Required Information * <br /> I 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C% <br /> For July 1, June 30, 19 <br /> ) Disposal Sites� <br /> Description(Make/Yr., Color) CAL, License No. CAL. License Renewal No. <br /> Serial No. _ t` <br /> Capacity ``!'"" ` Gal.,Weights 8.Measures No. <br /> =` 01,11 <br /> Equipmen'_ king Address <br /> f 2. ❑ PUMPER YARD , <br /> I For July 1, June 30, 19 f <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored } <br /> 3. ❑ PERCOLATION TEST R.S.or-R.C.E. No. <br /> f R.S.or R.C.E. Name �� � ` �+ C <br /> { (r _n Test Date/Time C <br /> Test Location , 04. <br /> 4. ❑ SANITATION PERMIT p t i, <br /> f Jab Address/Ldcation ! I � _ <br /> ( Address <br /> Owner LEACHING FIELD ❑ SEEPAGE PIT 1:1 PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL OTHER <br /> ❑ REPAIR � sv m 10 <br /> ❑ PERMANENT ❑ TEMPORARY NEW / <br /> 5. ❑ CHEMICAL:TOILETS For July 1,-June 30, 19 ! <br /> Disposal Site 't <br /> € Type Construction 4 .,* - . <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <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 /> F r <br /> [ application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that l have prepared this <br /> ordinances state laws, and ru es and regula o of the San Jaa uin L al Health district. <br /> APPLICANT'S SIGNATURE X <br /> 9 <br /> FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 R Received By January 31 July I &Received By Ju4y 31 <br /> Fee IS DUB: ❑ ANNUALLY REMIT <br /> - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT. <br /> FEE <br /> j <br /> LESS <br /> PRORATION <br /> f PLUS <br /> PENALTY <br /> OTHER <br /> 1 OTHER <br /> � Issuance Date Mai4ed flelive d <br /> Date Receipt No. Permi N . <br /> r .Received by _ 1601 E.HAZELTON AVE.,P.O. ox 2069 STOIC TON,CA, $201 <br /> APPLICANT—RETURN ALL <br /> 'COPIES TO: ENVIRONMENTA EALTH PE IT RVICE <br />