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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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildreth Lane <br /> a owner T. R. McDonald address Stockton, Ca 9521,2 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> j Contractor Licence No. 308171 <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc-Ise Renewal No. <br /> Capacity_ Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 Q <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/Locati n � ,�. <br /> O ner Add <br /> K El <br /> + , <br /> SEPTIC TANCESSPOOL LEACHING FIELD S11EEPAGE PIT PACKAGE PLANT <br /> El PERMANENT E] TEMPORARY NEW REPAIR ❑OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r j <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT iFor 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. ' 4. ""^'1r-•r <br /> IL <br /> I hereby certify that I�have prepared this applicat' n and that the work7WM be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul d r ulatio oft San Joaquin Lo al Heal District, <br /> APPLICANT'S SIGNATURE X <br /> 1425�-I <br /> FOR DEPARTMENT USE ONLY / <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July t &Received By 3uiy.31 <br /> Ar REWT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATES AMOUNT DUE CHECKED <br /> REMITTED <br /> AMOUNT <br /> FEELA _s S , <br /> LESS e <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER e <br /> l G{ <br /> OTHER <br /> 111, C>9 <br /> Received by Date Receipt No Permit ' 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 <br />