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Applications.Wili Se Processed When Submitted ProperlyCompleted Be SureTO sign 1newppucatlan. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) <br /> Address . 4645 HiHi l rlrath_i ane {' <br /> z Owner R1 MC DOna7 Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 93�;D497 Emergency Telephone No.� 957-4027 <br /> _J Contractor Licence No. 308171 -1' <br /> L Applicants Name (Print)—T h McDonald Title DAner. Date <br /> Please check Applicable Category (i1-7)and Fill in the Required Information I <br /> 1. ❑PUMPER VEHICLE PERMIT11REGISTRA"[ION (FOR EACH VEHICLE) {/Ir <br /> For July 1, June 30, 19 Disposal Sites �1\ <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 �M <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored l� ` <br /> No. of Chemical Toilets Stored I� <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.,or.R.C.E. No. <br /> Test Location IM Test Date/Time <br /> 4. ❑_SANITATION PERMIT <br /> Job Address/Locatio <br /> Owner Address `J <br /> ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 SEPTIC ANK ❑ CESSPOOL 'l <br />! ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Forst my 1, -June 30, 19 <br /> Type Construction A Disposal Site <br /> No. of Units V E=quipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Q� <br /> Operator Name 11' Where Certified <br />" Plant Location J1I <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 11,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a <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,! nd rules and regulatio of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> L BASE - EXPLANATION AMOUNTDUE CHECKED <br /> I DATE. DATE EMIT D AMOUNT <br /> �So � <br /> r <br /> . FEE � �, iM u <br /> LESS :IMS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - IIIIIID <br /> 1114 o . <br /> Received by Oate.k Receipt No. -Permit No. Issuance Date Mailed Delivered ' <br /> PP : .�. <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ., <br />