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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, 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 /> y Business Name (DBA) c B Address <br /> 4.645 Hildr th Lane <br /> z Owner T R McDonald. Address Same <br /> } <br /> Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. Emergency Telephone No. 957-AQ2 <br /> a <br /> Contractor Licence No. 13,3629 <br /> Applicants Name (Print) Title, Date ` <br /> Please check Applicable Category,(11-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 ---.pisposal Sites. <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL, License Renewal No. <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 <br /> 3. ❑ PERCOLATION TEST ` <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. ;. <br /> Test Location Test Rate/Time w <br /> 4. ❑ SANITATION PERM <br /> Job Address/Location <br /> Owner Address i <br /> SEPTIC TANElLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> O �ESSpo� <br /> PERMANENT D TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> -5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 \ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cieaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name - <br /> 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. s <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, a d rules and regulation the Sara Joaquin cal Health District. i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 eceived By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 11 AMOUNT , <br /> FEE- LA-S. <br /> I, LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> l <br /> OTHER <br /> Received by Date` Receipt No. Permit No. Issuance Date^ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES'TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 _ STOCKTOK CA 95201 <br />