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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> W` (For Non-Transferable,revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT �6 <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) .,Address_ „ 6 4 511! J dr A-th Ltano <br /> aOwner T....-R. Mn17nnal d._. Address <br /> Firm Partners, Addresses and Telephone Numbers - <br /> a Business Telephone No. 9 3 1 _n L 9 7 - Emergency Telephone No. _ 957-4027 <br /> Contractor Licence No. T 3 3{-7 9 - <br />" Applicants Name (Print) T _ R. McDonald Title nTin P-r Date, j <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) '* N r- <br /> For July 1, _ = June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) _ - <br /> Serial No. _ CAL. License No. { .-� n CAL"LicenseRenew la No. <br /> Capacity f_ Gal.,Weights & Measures No.E <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD -z r " <br /> For July 1, -16�1 June 30, 19 <br /> No. of Vehicles Stored ` <br /> No. of,Chemical Toilets Stored ttt <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.•Name ) ` f R.S. or R.C.E. No. ► <br /> Test Location •^ ) 'A a - A '' Test pate/Time f <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location t J <br /> Owner Address ¢ <br /> ❑ SEPTIC TANK ❑ CESSPO ❑ LEACHING FIELD D SEEPAGE PIT t❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW _ ...,•�....El REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I <br /> f <br /> Type Construction Disposal Site <br /> No. of Units f Equipment Storage/Cleaning Location(s)0- .c <br /> 6. ❑ P.ACKAGE,TREATMENT PLANT For July 1, -June 30, 19 (� <br /> r ' y i �- +Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant'Capacity ( No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ' <br /> ❑-DRY_CL-EANING Chemicals Used/Amount/Mo.� I <br /> ..- .,..,r..., ....�....�...�,..�.. <br /> t i <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin County <br /> ' i <br /> ordinances, state laws, and rules a d e Ula ns f the San Joaquin ocal Health District. (�I <br /> ( <br /> APPLICANT'S SIGNATURE X etlT Z <br /> jo <br /> _VY, toi?�p <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January+I &Received By January 31 ❑ July 1 &Received By July 31 <br /> ----_ r REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT , <br /> FEES.QD I 'l�S.[JU ✓ <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER s_ <br /> OTHER <br /> t63 74 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered �' F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />