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ApplicationsWill 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'urisdigtional area of the Sf� �jo q i c I Heai h trict <br /> H Business Name (DBA) McDonald SeptlCt Tank Service Address T�' D �dreti ane <br /> t Owner nalCl Address 3a1T10 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 108173 <br /> L Applicants Name (Print) T R T Title Owner Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19"� �D'isposai Sites <br /> Description(Make/Yr., Color) <br /> Serial No. k CAL. License No. <br /> CAL, Licc,lse Renewal No. <br /> Capacity . Gal., Weights&'M' N � <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT , <br /> Job Address/Location I <br /> goSne rAddress EPTIC TANK ❑ CESSP L LEACHING FIELD ❑ SEEPAGE PIT ❑"PACKAGE PLANT I <br /> 13PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER O <br /> 5. ❑ CHEMICAL TOILETS For July 1, - <br /> June 30, 19 411 1 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 A4 <br /> Operator Name Where Certified <br /> Plant Location ! <br /> Plant Capacity - No.Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19_ -1 -i �' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., _t❑itMdre'Thari 1,000 Sq, Ft-i.1 L <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMa. <br /> Y� t <br /> I hereby certify that I have prepared this application d that the work will be done in accordance with San Joaquin County <br /> ordinances, state la71;7M <br /> reg do s of t a Joaquin Local Health rlCt. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CH CKED <br /> FEE AM U T <br /> LESS �� r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date �� <br /> Receipt No. Permit No. ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />