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I Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t (For Non-Transferable, Revocable, and Suspendable) –Q <br /> SEP7AGE <br /> ENVIRONMENTAL HE=ALTH PERMIT f <br /> i LIQUID WASTE p <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District pp <br /> IF Business Name (DBA) CD nal Address l <br /> T. R. McDonald Address Qnrne <br /> z Owner <br /> LJ Firm Partners, Addresses and Telephone Numbers <br /> k <br /> a Business Telephone No. 431 —0497 Emergency Telephone No. 957-4027 <br /> �Contractor Licence No. - <br /> Applicants Name (Print) Title - Date <br /> Please check Applicable Cltegory (1-7) and Fill In the Required Inlormalion <br /> 1: "❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <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-LocationTest Date/Time c <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location t <br /> Owner !Add isV ) C <br /> ❑ SEPTIC.TANK ❑ CESSPOOL REACHING FIELD 13 SEEPAGE PIT 11 PACKAGE PLANT r <br /> ❑ t'9:fN-ZiANEN.T 0-,-TEMPORARY 1 `,NEW REPAIR OTHER SUln^ rS <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 J <br /> Type',Construction Disposal Site <br /> No. of Units u �• Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT/For July 1, -June 30, 19 <br /> Operator Name i1-- Where Certified <br /> Plant Location — - -- - - <br /> f Plant Capacity ^�i NO Units Served. <br /> L <br /> r � 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ­0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 S7- et.* <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k <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, and rule and regulatio th-San Joaquin Loca ealth District. <br /> APPLICANT'S SIGNATURE X <br /> FO DEPARTMENT USJp LY <br /> I �- <br /> �, Fee is Due: ❑ ANNUALLY ❑ PER UNIT •PER SITE <br /> El ❑ nuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING ITTANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> r <br /> OTHER <br /> G51 _ <br /> a' <br /> 7.9 1.0 ss Received by Date Receipt No. Permit No. Issuance to Mailed7 Deliver d <br /> APPLICANT'RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,C 95201 <br /> Z. <br />