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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appy %fion. <br /> APPLICATION <br /> �.�=✓`'y-� ''� <br /> _'% (For Non-Transferable, Revocable,and Suspendable)� , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f <br /> LIQUID WASTE <br /> ` Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)�MCDOn.a1d Septic Tank - Serttce Address 464S Hildriath I P_ <br /> aOwner- --- T. 'R. McDonald Address <br /> Firm Partners,Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. <br /> ' aContractor Licence No. 308171 <br /> Applicants Name (Print) -T• R. McDonal Title Date <br /> f Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> L For July 1,—' June 30, 19`� Disposal Sites <br /> Description(Make/Yr., Color) <br /> k Serial No. CAL, License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD t r <br /> For July 1, June 30,'19 ' <br /> No, of Vehicles Stored t <br /> No. of Chemical Toilets Stored R <br /> i 3. ❑ PERCOLATION TEST r f <br /> Y y.sr+.a <br /> R.S.or R.C.E. Name R.S. or R.C.E. No.!., <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ) <br /> Job.Address/Locatio <br /> ,.. Owner Addres <br /> 4 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT Q <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER O <br /> 5A❑ CHEMICAL TOILETS For July 1, -Ju a 30, 19 CA <br /> Type Construction Disposal Site <br /> k No. of Units Equipment Storage/Cleaning Location(s) — - <br /> B. -❑ PACKAGE TREATMENT PLANT For-July 1, -June 30, 19 ' <br /> F Operator Name Where Certified, <br /> Plant Location ) £ <br /> .Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ` • r <br /> SIZES ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. °g <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. IL <br /> t 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, and rules and re uiations a San Joaquin Lo I Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> T- - _ REMIT <br /> .-BILLING `REMITTANCE S AMOUNT DUE' CHECKED <br /> BASE EXPLANATION PATE DATES REMITTED <br /> AMOUNT <br /> FEES <br /> LESS L ' ``�� <br /> PRORATION 1 <br /> PLUS <br /> PENALTY r <br /> OTHER /� WPV <br /> OTHER126 <br /> + <br /> i <br /> Received by Date, Receipt No. Permit No. Iss a e DaIC Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 <br />