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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - ,N (For Non-Transferable, Revocable, and Suspendable) ? <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE j <br /> LIQUID WASTE AJ-' 2 ( 7—LQ <br /> Application is hereby made to carry on business in-the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (RBA)_Me Donald SeptiC-�, Taink SeryiCddress <br /> z Owner <br /> T. R. MGDon Address same I <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> MBusiness Telephone No. 931-0497 Emergency Telephone No, 997-4027 <br /> Contractor Licence No. 308171 <br /> L Applicants Name (Print) T. R. McDonald Title .., Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s <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. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> V <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> F <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 /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> OwnerI ' Address <br /> SEPTIC TANK CESS OOL LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT ' <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �. <br /> Type Construction Disposal Site <br /> t <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 7 j <br /> 7. ❑kLAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. FE <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �a 4 <br /> r I hereby certify that I have prepared this applic ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and r ulatio f e San Joaquin LogeM Health District. <br /> APPLICANT'S SIGNATURE X <br /> i` FOR DEPARTMENT USE <br /> j <br /> Fee Is Due, ❑-ANNUALLY ❑ PER UNIT PER SITF ❑ EACH Ja ry 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> - REMIT <br /> BASE EXPLANATION BILLINGREM ANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT I <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> i <br /> i OTHER <br /> O 193 j <br /> q 7 <br /> Received by Date - Receipt No. Permit No. Mailed - Deli ered <br /> APPLICANT—RETURN ALL COPIES TO, NYIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.sox 2048 'ST CKT 5201 _ <br />