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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 Sus endable - <br /> P ) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE 4 <br /> i. IL I <br /> — ILIQUId WASTE '.. <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin"Local �Zst&"�'ty Business Name (DBA) McDonald SeRtic Tank' S -rvice Address D ' <br /> Owner T. R,II McDonald Address <br /> ti <br /> J,Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 931-o-497Emergency Contractor Licence No. 30$1];7 g y Tele phone No. 957-4.027 <br /> 4 - - <br /> a Applicants Name (Print) T. RJ,.McDonald <br /> L Title _Qj�hP� _ Date <br /> Please check Applicable Category (1-7)and Fill in the Required Iniormation <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATIONI(FOR•EACH VEHICLE) ` <br /> _30–, <br /> For July 1; � ��`"Jusne e 30, 19 ��. � Disposal�ites <br /> Description(Make/Yr., Color) <br /> Serial No. +IE —. r <br /> '` - CAL. License No. CAL, Liccrlse Renewal No. <br /> Capacity I�Gal., Weights & Measures No. ` <br /> Equipment Parking Address l <br /> 2. ❑ PUMPER YARD ",J! t f. <br /> For July 1, June 30,'z19_a `= <br /> No. of Vehicles Stored ' <br /> E <br /> No. of Chemical Toilets Stored �N <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. C3 SANITATION PERMIT � ^� f <br /> x <br /> Job Address Location (f t <br /> i <br /> Owner Address <br /> SEPTIC TANK ❑ CESS OOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT # <br /> KPERMANENT [] TEMPORARY EW ❑ REPAIR EI-OTHER <br /> EI CHEMICAL TOILETS For July 1, -Jun •30,-19 .r <br /> Type Constructions - i - Disposal Site ' <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE.TREATMENT PLAINT For July 1, -June 30, 19 t r 41 <br /> Operator Name Where Certified r <br /> Plant Location �� { <br /> Plant Capacity No. Units Served ' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.e" ❑ More Than 1,000 Sq Ett t# <br /> ❑ DRY CLEANING, Chemicals Used%Amount/Mo. t <br /> I hereby certify Ihat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ry Iles egulations of S Joaquin Local Hea h Di ct. <br /> APPLICANT'S SIGNATURE X <br /> +FOR'DEPARTMENT USE ONLY <br /> r <br /> Fee Is Due: ❑ ANNUALLY_ ❑ PER UNIT ER SITiF 0-EACH ❑ January 7 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE i EXPLANATIBILLING REMITTANCE $ AMOUNT DUE CHECkFD <br /> DATE REMITTED AMOUNT <br /> LESS00, <br /> t , <br /> PRORATION - <br /> PLUS i 3 <br /> PENALTY _- <br /> OTHER <br /> OTHER <br /> FzReceivedby Date �jP- Receipt No. Permit No. .Issuance Date t7Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STD TON,CA <br /> ` i <br />