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Applications Will Be Processed When Submitted Properly Completed. BeSureTo signTneApplicallon. <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 /> N Business Name (DBA) McDonald Septic 'lank Service Address 4645 Hildreth Ln <br /> T. R. McDonald Stockton, Ca 95212 } <br /> za Owner Address <br /> Firm Partners, Addresses and Telephone Numbers 9$7-4027 <br /> aBusiness Telephone No. 931--0497 Emergency Telephone No. <br /> Contractor Licence No. 308171 - <br /> LApplicants 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) 1 <br /> Serial No. CAL. License No. CAL. Lic:-nse Renewal No. <br /> Capacity ` Gal., Weights & Measures:No. <br /> Equipment Parking Address r <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 0till.� <br /> No. of Vehicles Stored 1 h <br /> No. of Chemical Toilets Stored t t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> E /5 <br /> Test Location -- Test Date/Time <br /> .y s <br /> i <br /> — <br /> 4. ❑ SANITATION PERMIT Ftlr, -Job Address/Location I L } <br /> Owner Address z r — - '. ' " <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT, PACKAGE PLANT; ON <br /> r <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER { <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 j <br /> Type Construction I Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For-July 1, -June 30, 19 <br /> Operator Name Where Certified i <br /> Plant Location a, 1► <br /> f No. Units Served <br /> Plant Capacity -.- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,00.00 Sq. Ft. 9 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 7Pt. <br /> I hereby certify that I have prepared this applicatiN dnd of the work will be done in accordance With San`-d aq in County t <br /> ordinances, state laws, and r es and regul ns of the San Jo uin Loyal Health Dis`'ricctq , <br /> APPLICANT'S SIGNATURE X, <br /> s� � WyoS <br /> FOR DEPARTMENT USE ONLY hh <br /> Fee Is Due: ❑ ANNUALLY ❑ PER KNIT. ❑ PER SITE ❑ EACH - ❑ January 1 &Received By,�-�nuary 31 my Receive y July 31 .� <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE A T DUE ECKED <br /> DATE DATE REMIT AMOUNT <br /> FEE <br /> 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 7 <br /> Received by - - Date Receipt No. Permit I u n e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E..HAZEL E.,P.O.Box 2009 STOCKTON,CA 95201 <br />