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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> APPLICATION <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 /> Business Name (DBA) McDonald Septic Tank Service Address 4644 Hi 1 rlrPth 7 ane <br /> z Owner T. R. MCDQnald Address Stnrktnn, Cn 9%212 <br /> a -- <br /> J.Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 931-0497 Emergency Telephone No. 957-40 <br /> Contractor Licence No. '109171 <br /> �Applicants Name (Print) T_ R_ MrDnna1 d Title Own t.r Date ' <br /> Please check Applicable Category (1-7) and Fill in the Required Information Q1.0 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR_EAC H V�EHICLE)* <br /> For July 1, June 30, 19 ,} #rDisposal Sites ► <br /> Description(Make/Yr., Color) . <br /> Serial No. CAL. License No. CAL. Licc,-ise Renewal No. t <br /> Capacity Gal., Weights & Measures No. r <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD f <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 t _ Test Date/Time e t <br /> 4. ❑ SANITATION PERMIT �� 1 <br /> Job Addres ocation <br /> Own r Address � # 1 <br /> EPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PAC AGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER 3SU�'1 i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �rj <br /> Type Construction Disposal Site 1 I <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 A <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served 0 ; <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 /> 3 t <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 regulations Ch Nsan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X j <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑yJ("t,,&Received By July 31 <br /> BILLING REMITTANCE; t REMIT <br /> BASE EXPLANATION �: t iAMOUNT"DUE CHECKED <br /> DATE DA Ei � RI=MITT,gD „ i i {' AMOUNT tt <br /> FEE <br /> �t <br /> LESS I <br /> PRORATION - <br /> PLUS <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> Received by Date — Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009.. STOCKTON,CA 95201 i <br /> . J s <br />