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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTnePtppimanon. <br /> APPLICATION <br /> ..; a (For Non-Transferable, Revocable,'and Suspendable) rSEPTAGE I <br /> ENVIRONMENTAL'.-HEALTH PERMIT � <br /> �.; <br /> LIQUID'WASTE-=�9 -- i <br /> Application is hereby mad_e.to carry on bus ess in the Jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) McDonald Address <br /> 46 I-5AIi-1 drE-th Lan" <br /> z Owner T. *Address_ 4645 Pi Lane <br /> a �r_. e <br /> L) Firm Partners, Addresses and Telephone Numbers,' .- �r527 <br /> a 9'31-0 ,97-1-110" = Emergency Telephone No., 457 <br /> a Business Telephone No. <br /> •_, Asa. - <br /> Contractor Licence No. Y. _ <br /> L Applicants Name (Print) "� � - ` _ Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information k <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION_(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites. == <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ^ , <br /> 2. ❑ PUMPER YARD `v <br /> For July 1, June 30, 19 r <br /> No. of Vehicles Stored <br /> x ."°�� <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._ fn, _ <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT L <br /> CAf <br /> Job Address/Location 1 <br /> Owner P Address <br /> SEPTIC TANK rl CESSPOOL tEAC NG FIELD 'SEEPAGE PIT ❑ PACKAGE PLANT 1 <br /> PERMANENT ❑ TEMPORARY ` EW IJ REPAIR 13-OTHER- <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 <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 <br /> T Where Certified <br /> Operator Name } <br /> Plant Location - <br /> No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July i, -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 /> '1 <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, and rules and regulations oft an Joaquin Local ealth strict. <br /> I APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 111 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT %PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑.July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by <br /> Date Receipt No. Per it No, Issuance Date Mailed Delive ed <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL REALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 95201 <br />