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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1 <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)_McDon@.1 _®_ J�.�� }31.s—cu`r_C Address <br /> z Owner L Address -o <br /> a - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 9 31 –0 4 9 7 Emergency Telephone No. <br /> Contractor Licence No. 308� 71 <br /> LApplicants Name (Print) T- R. Mc Do n A l d Title Date r <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 01 <br /> For July 1, June 30, 19 Disposal Sites Is <br /> v + <br /> Description(Make/Yr., Color) .0�. <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gai., 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 <br /> Job Address/Location (� <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT _ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I © REPAIR ❑ OTHER i C/) <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> F <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 <br /> Operator Name I I Where Certified <br /> F <br /> Plant Location I _ _ _ <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 /> I - <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE JNLY <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 $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 6a <br /> FEE <br /> 446 <br /> LESS <br /> PRORATION <br /> PLUS "U✓�Q /7 <br /> PENALTY i� <br /> OTHER <br /> OTHER / <br /> Av <br /> Received by Date Receipt No. Permit No suanc Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />