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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is her ��yy made o b s' a isdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) MC D�SNALD �C ['` Er Address 4645 HILDRETH LANE <br /> a Owner T. R. MC DONALD Address SAME <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 9.3.1=9497 Emergency Telephone No. 957--4027 <br /> Contractor Licence No. 30 8171 <br /> L Applicants Name(Print) T. R. MC DONALD 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 <br /> Description(Make/Yr., Color) <br /> Serial No. _ CAL. License No: CAL, Licc,nse 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 /> 4. ❑ SANITATION PERMIT ©* 0 <br /> Job Address/Location <br /> Owner Address <br /> 13 SEPTICTAN ❑ CESSPOOL br <br /> LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAI �/ _❑ THER� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �9��xX15 .�&� <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 iS'l <br /> Operator Name Where Certified �J <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 /> 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, an rules and regulati of the San Joaquin Loc I Health District. <br /> APPLICANT'S SIGNATURE.. Ia <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received ey July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE D REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> �{� . 4i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d��ta;S 1 Ia-il�r <br /> Received by Date Receipt No. Permit No. uan a Date Mailed Delivered <br /> i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,-P.O.Box 2009 STOCKTON,CA 95201 <br /> � f <br />