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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. L <br /> 4 APPLICATION <br /> (( 0� (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGL <br /> _ LIQUID WASTE <br /> x Application is hereby made to carry on business in the jurisdic)ional area of.the San Joaquin Local Health Distrilct <br /> y Business Name (DBA) McDol1alC� Septic Tank SerVi re 4645.-Aildreth Lane <br /> aOwner T. R. M-0-011-c-d_1 - Address Same <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. - __ Emergency Telephone No. - 957-4027 <br /> Contractor Licence No. 30$171 Irl <br /> Applicants Name (Print) _ T. R-._..McDo 7a1 d _....___....__. Title Oyrnnr Date 1 <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. Licc.,ise Renewal No.--- <br /> Capacity _ Gal.,Weights.& Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD A' <br /> For July 1, June 30, 19 w y <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location TeU Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> SEPTIC TA K ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT- ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR 11 OTHER C <br /> 5. 11 CHEMICAL TOILETS For July 1, -Ju'to <br /> 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 /> Operator Name Where Certified <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. <br /> . r - <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done inaccordance with San Joaquin County <br /> ordinances, state laws, anq rules and regulations of the an oaquin Local Health rY t <br /> APPLICANT'S SIGNATURE X <br /> lyr <br /> FOR DEPARTMENT USI ON <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ A' a 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REM VE= $ REMIT <br /> BASE EXPLANATION. AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEE 5 - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> - I <br /> OTHER_ <br /> OTHER <br /> ! S d _. c <br /> Received by Date Receipt No. Permit�No. lssoaryce Date` Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SE 'S-r-0' 1601 E.HAZELTON AY ., .Box 2009 STOCKTON,CA 95201 - <br />