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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 5EPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) McDonald' Se tic Tank Service Address 4645 Hildreth Lane 95212 <br /> a owner . T. R. McDonald Address 4645 Hildreth Lane 95212 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 931-0497 Emergency Telephone No. <br /> Contractor Licence No. 308171 <br />�. Applicants Name (Print) T 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) p� <br /> For July 1, June 30, 19 Disposal Sites 1 <br /> Description(Make/Yr., Calor) <br /> k, Serial No. CAL. License No. CAL. License Renewal No. , 1 <br /> Capacity Gal.,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 q' <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. 11 SANITATION PERMIT /7-ell <br /> Job Address/Lo tion <br /> Owner ddress <br /> SEPTIC TANK rr❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW + REPAIR ❑ OTHER <br /> 5.�❑ CHEMICAL TOILETS For July 1, -Jun 30, 19 m <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 /> Operator Name Where Certified <br /> i 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. <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 regulatio the San Joaquin Local ealth 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 $ REMIT <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Y 7� <br /> LESS <br /> PRORATION _ r <br /> p <br /> 1 PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> r <br /> k Received nyDate Receipt No. Permit No.M ssuance Date Mailed De vered Q <br /> APPLICANT-RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEyi014AVE jP.O..Sox 2009 g-5T CKT N,CA 9520'l <br />