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rj Applications Will 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 S�PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 1 <br /> U Business Name (DBA) McDonald Septic Tank Service Address 4645 Hi l dreth Labe <br /> z Owner T. R. McDonald Address Same <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 1 <br /> Contractor Licence No. 308171 �� 1 <br /> LApplicants Name (Print) T. R. McDonald Title Owner 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. CAL. License No. CAL. Liccnse Renewai No. <br /> Capacity Gal„Weights & Measures.40. ' <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 � r,. <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 11 SANITATION PERMIT. <br /> Job Address/Location <br /> Owner Address - <br /> SEPTIC TANKf 11CESSPOOL /� LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT+ <br /> E] PERMANENT ❑ TEMPORARY 1 VEW ❑ REPXlR ❑'OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July .1,`June 30, 19 ' ^ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAG6 TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> - <br /> Plant CapacityNo. Units Seryed 11 <br /> 7. ❑ LAUNDRY For.July:1, -June 30, 191�s = , <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More T an1:,00o Sq. Ft. , <br /> ❑ DRY CLEANING; Chemicals Used/Amo.unt/Mo. <br /> rill <br /> �I hereby certify that I have prepared this application and that the work will be done in ccord nce with San Joaquiri'County} <br /> ordinances, state laws, and rules and regulation the San Joaquin Lo al Health Distr' � <br /> APPLICANT'S SIGNATURE X <br /> 1 a <br /> 14. <br /> FOR DEPARTMENT EO <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH an y 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMI NCE $ REMIT <br /> BASE l EXPLANATION DATE E REMITTED AMOUNT DUE CHECKED <br /> Z' DATE AMOUNT <br /> zr <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 41( <br /> PENALTY <br /> OTHER <br /> OTHER <br /> taS � <br /> Received by Date Receipt No. Permit No. uan Date M 'led Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE., ow 2009 STOCKTON,CA 95201 <br />