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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> I APPLICATION I <br /> a (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 /> w 1—mess Name (DBA) MCDOna�tJC 4arVi CP Address Lf_ .__u;1,1roi-L, T ne <br /> Owner T_ R M nnn a 1 ri Addressdc <br /> �'3TF1P <br /> j Firm Partners,Addresses and Telephone Numbers <br /> a Business Telephone No._931-0497 Emergency Telephone No. 97-402] I <br /> Contractor Licence No. 308171 <br /> d <br /> LApplicants Name (Print) R Title OSn1T]2X 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., Color) <br /> Serial No. f CAL. License No. - CAL. Liccnse Renewal No. <br /> Capacity Gal„Weights&Measures No. <br /> Equipment Parking Address :I <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 t <br /> R.S.or R.C.E. Name t_ R.S.or R.C.E.'No. ._ <br /> Test Location i ` ' I Teat Date/Time.r <br /> 4. ❑ SANITATION PERMIT � <br /> Job Address/Loca ' n <br /> i M <br /> Owner Address ) <br /> ❑ SEPTIC TANK ❑ CESSPOOL LE CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT �I <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW' REPAIR ❑ OTHER Vol <br /> S. 13 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Construction Disposal Site i <br /> ...of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June.30. 19 ' <br /> Operator Namewhere Certif led <br /> -4l <br /> Plant Location <br /> Plant Capacity No. Units Served _ ~N <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 /> J <br /> I hereby certify that I have prepared this applicat and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,a r d r uI do f th San Joaquin L cal Ith District. <br /> APPLICANT'S SIGNATURE X I' OL-x'Z j <br /> 6 <br /> f$ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1$Received By January 31.T ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> rr- <br /> OTHER <br /> P <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Malted Delivered, <br /> APPLICANT—RETURN ALL COPIES To. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AYE.,P.0.Sox 20119 STOCKTON,CA 95201 •, <br />