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"Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable,and Suspendable) <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 /> O Business Name (DBA) McDonald Septin Sprvi r•a Address4 645 la11dret-h Tana 0) <br /> a Owner T. R. MC Donald Address same t <br /> ZO Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-4097 <br /> Contractor Licence No. 308171 <br /> Applicants Name (Print) T.R. MCDOnald Title OTAMer - Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ti <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. w <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 4 <br /> No. of Vehicles Stored C <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <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 <br /> Job Address/Location <br /> OwnerAddress <br /> 11 SEPTIC TANK CESSPOOL LEACHIN FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT J� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER " <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ 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 /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Countyl <br /> ordinances, state laws, a d rules and regulations of San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �I No 7C, CA'f2, FOR DEPARTMENT USE ONLY <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE RFMITTED AMOUNT <br /> FEE / ~ <br /> LESS r <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER <br /> JJ <br /> OTHER <br /> 79-I a IZ 1-79 <br /> R ceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO`. "ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 2 <br />