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APPLICATION <br /> I J/.. l%f• 4,wor Non-Transferable, Revocable, and Suspendab.,,,, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> �g y rrd �p LIQUID WASTE <br /> r Application isMhe6b I Ue JeaIzi C�"anr�ces�ierViC2 dictional area of the San Joaquin Local Health District <br /> y <br /> Business Name (DBA) Address 4645 Hi 1 dreth Lane <br /> i Owner T R. McDonald Address Same <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers — N <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-4027 ) <br /> Contractor Licence No. .108171 <br /> Applicants 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) <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 Te t nalp/Tinne <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ <br /> Owner Add r s <br /> SEPTIC ANK CESSPOOL LEACHING FIELD ff SEEPAGE PIT ❑ PACKAGE PLANT tj <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Juhe 30, 19 p <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 /> Plant Location �1 <br /> Plant Capacity No. Units Served O <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 S <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done i aC 1 d dance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of t San Joaquin Local He th Dist I / - <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMEN SE Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH uary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE ANCE g REMIT <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS --- -- ------ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by pate Receipt No. Permit No. Issuarice D �'O-M'-.11-1 <br /> d Delivered � <br /> APPLICANTt—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON 2009 STOCKTON,CA 95201 <br /> f 1.+ <br />