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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. V <br /> A� <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 ty�d <br /> h Business Name (DBA)—TZCDOnalSe tai r Tann Se_ruj rA Address <br /> aOwner T. R. McDonald Address aamp <br /> zu Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 931--0497 <br /> P Emergency Telephone No. 957-4 <br /> - Contractor Licence No. 308171 <br /> Applicants Name(Print) T. R. McDonald Titler <br /> {��7t,1P�.� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <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 r- <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 '- <br /> Owner Address <br /> SEPTIC TANK CESSP60t LEACHING FIELD -^SEEPAGE PIT ❑ ACKAGE PLANT <br /> PERMANENT ❑ TEMPORARYNEW ❑ REPAIR 13 OTHER <br /> 5. 13CHEMICAL TOILETS For July 1, -J ne 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 n <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <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 /> I hereby certify that I have prepared his applicatiorragd that the work will be don in accordance with San Joaquin County <br /> ordinances, state laws, and rule aryd ragylotions of the San Joaquin Local alth istrict. <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 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMIT <br /> REMITTANCE $ IAMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> —1 b IV <br /> Received by Date Receipt No - Permit No. Issuance Date Mailed 7Delive d <br /> APPLICANT—RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELT4N AVE.,P.O.box 2009 STOC TON,C 95201 <br />