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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLE AMN <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <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) McDonal d Septi c Tank Servi ce Address 4645 Hi 1 dreth Lane <br /> T. R. McDonald $tee <br /> a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a931-0497 Telephone No. g31-0497 Emergency Telephone No. 957-40)77 <br /> Contractor Licence No. 308171 <br /> T. R. McDonald Owner <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> (t ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 1 <br /> FoPJuly 1, — 4 June 30, 19 '�" 3 Q-A* ,t i Disposal Sites <br /> Description(Make/Yr., Color) 00 <br /> Serial No. CAL. License No. CAL. Licc;ise Renewal No. <br /> Capacity Gal., Weights &Measures No. }rt <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 =4 ,'• <br /> No. of Vehicies Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S'or R.G.E. No. <br /> Test Location �JP0 Date/Time <br /> 4. 1:1 SANITATION PERMIT �� ` <br /> Job Address/L cation <br /> p <br /> Owner _ _ A s <br /> SEPTIC TANK ❑-CESSPOOLLEACHING FIELD ❑ ❑ ACKAGE PLANT <br /> ��� �-' <br /> ❑ PERMANENT ❑ TEMPORARY NEW � � ❑ REPAIR ❑BOTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - <br /> f <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locatiori(s) <br /> !. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name r -T# Where Certified <br /> Plant Location A I <br /> Plant Capacity er No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Mor�Than 1,000 Sq.'Ft.' ti <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 rules and regul s of the an J aqu' Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> REMIT � <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE `� DATE" —� "'"`I—REMITTED AMOUNT <br /> --AMOUNT.DUE_ CHECKED, ,a r <br /> AMOUNT <br /> FEE �5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER j <br /> V1 -I his to <br /> Received by Date Receipt No. Permit No. Issuance Date MailedDeli ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 KTON,CA 95201 <br />