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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> ..6 APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> F. ENVIRONMENTAL HEALTH PERMIT 4- 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 /> rBusiness Name (DBA) ar011 Address 4645 11ildreth Lane <br /> T. IMcDonald1 d s - -- <br /> aOwnerAddress <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 931.-U4g7`F Emergency Telephone No. 957-4027 <br /> Contractor Licence No. T• CD' T al.d <br /> I Applicants Name (Print)____ f. ,���.J` Title Date e� <br /> Please check Applicable Category (1-7)and Fill In the Required Information �l <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30;,19 t.. 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. (��/J`_7�] <br /> -1 <br /> I. Test Location "°"""`""'Test Dat27Time"""""—`�""" <br /> 4. ❑ SANITATION PERMIT i <br /> f Job Address/Location `C <br /> I Owner Address <br /> ? SEPTIC TANK ❑ CEr' POFARY <br /> OL X ACHING FIELD SEEPAGE PIT C1 PACKAGE PLANT <br /> PERMANENT ❑ TE NEW ` ❑:OTHER: .� ��„ REPAIR Mix b <br /> 5.; CHEMICAL TOILETS For July 1,'June 30,',19 ya, <br /> Type Construction J Disposal Site 1 <br /> Nb.of Units Equipment Storage/Cleaning Location(s) 4 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,°-June 30, 19 <br /> Operator Name Where Certified " <br /> Plant Location a <br /> Plant Capacity No.a T No. Units Served ice. <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - ' - <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,,Chemicals Used/Amount/Mo. r r - � <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 ruts andrregulati s of the San Joaquin ocal Health District. <br /> I APPLICANT'S SIGNATURE X <br /> i.,. .FOR DEPARTMENT,USE-ONLYt 1. <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑yEACH ❑'January 1 8 Received By January 31 ❑ July 1 &Received By July-1.1--- <br /> I BILLING REMITTANCE '$.* <br /> r REMF r <br /> BASE EXPLANATION AMOUNT DUE CWECKED <br /> DATE DATE REMITTED ;N�AMOUNT <br /> l <br /> FEE <br /> ' LESS - <br /> PRORATION <br /> PLUS g fir. <br /> PENALTY i �t <br /> I � ,. . <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No • lfsqance Date Mailed Delivered <br /> APPLICANT—RETURN ALL CO_ f IES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601,E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 <br />