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�.:aiions Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> -APPLICATION <br /> I <br /> (For Non-Transferable, Revocable, and Suspendable) SirP7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I �n BI S-mess Name (DBA) McDonaldSIA Address a <br /> I. z Owner T Address S amp ~ <br /> fa <br /> JFirm Partners, Addresses�� -40 <br /> Telephone Numbers <br /> CL <br /> Business Telephone No. 1-0497 Emergency Telephone No. <br /> 957 97 <br /> 308171 1 <br /> Contractor Licence No. _ rs <br /> LApplicants Name {Print) T. R. McDonald Title _ Owner Date <br /> *.S I i <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 "~ I"1- Disposal Sites- _x4e j, <br /> Description(Make/Yr., Color) <br /> GAL. Licc <br /> Serial No. CAL. License No. se Re�ewaf 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 f. <br /> R.S. or R.C.E. Name R.S.or R.C.E. Na.�� <br /> ii . .. t w i �J. .i ,. %0F Test Location Test Date/Time <br /> t <br /> ' 4. ❑ SANITATION PERMIT � IN <br /> u �. <br /> Job Address/Location r <br /> caner Address <br /> SEPTIC TANK ❑ CESSP ~OL LEACHING FIELD ❑ SEEPAGE PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY.` ❑ NEW /�REPAI f -- ❑.OTHER jam% r <br /> S. ❑'CHEMICAL TOILETS' For July 1,-June 30, 19 ?p� 1�x Zlr <br /> Type Construction Disposal Site <br /> --r� <br /> k <br /> r No. of Units Equipment Storage/Gleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certit d d"" <br /> Plant Location .rpt <br /> Plant Capacity t No. Units Served t <br /> 7. ❑ LAUNDRY For July 1, -June 34, 19 --- •---� �, r <br /> �k SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. -„ ? <br /> ! ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> fff I <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 rules and regulations of San Joaquin Loc Health District. .. <br /> APPLICANT'S SIGNATURE Xir <br /> FOR DEPARTMENT USE ONLY «—^ <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&FReceived By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT <br /> _ BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE j E7(PLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS P J <br /> PRORATION - <br /> i PLUS <br /> PENALTY <br /> t OTHER <br /> OTHER• <br /> I Received by - Date Receipt No. Permit No. O issuance Date Mailed Delivered f <br /> r APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 E.HAZELTON.AVE.,.P.O.11 2009 STOCK 95201 r_ <br />