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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f APPLICATION <br /> \ (For Non-Transferable, Revocable,and Suspendable) SEPTAG-E <br /> `,� ENVIRONMENTAL HEALTH PERMIT <br /> k LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F <br /> i Owner Business Name (DBA) 1,ic0onald Septic Tank Service Address 4645 Hildreth Lane <br /> T. R. McDonald Address 4645 Hildreth Lane <br /> a <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 108171 <br /> Applicants Name (Print) T_ R. McDonald Title Owner Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites L <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER 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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> ❑ SANITATION PERMIT <br /> Job Address/Locayon <br /> Owner a zzv Address <br /> SEPTIC ANK CESSP OL LEACHING FIELD ( SEEPAGE PIT PACKAGE PLANT <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 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 regulatio the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> `x, FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT I PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �S 1( <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1-7 39 <br /> q11 I <br /> Received by Date Receipt No. er i o. I suan a Date Mailed Deliverdid <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT 0 <br />