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' Applications Will Be Processed When Submitted Properly.Completed. BeSure o g <br /> APPLICATION ° <br /> r (For Non-Transferable,Revocable;and Suspendable) SEPTAGE f <br /> ENVIRONMENTAL HEALTH PERMIT ° <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Jaquin Local Health District <br /> conald Septic & Backhoe Address �9 <br /> MD5 Hil'dre.th Lane <br /> Business Name (DBA)_ . Battle <br /> i Owner '.y -T. R. McDonald Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers 9'S rj_��2 <br /> a Business Telephone-No. l-0 7, Emergency Telephone No. <br /> -.: 1 6 7 i . <br /> Contractor Licence No. Owner Date _ f <br /> LApplicants Name (Print) �• R,..: Me Donald Title ' _J <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ' <br /> For,.truly 1, - June 30, 19;= Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. . <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weigbts &Measures No. <br /> ` Equipment Parking.Address . <br /> 2. ❑ PUMPER YARD 4 7 <br /> For July 1, June 30; 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> y s r R.S�or.R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Nest Date/Ti <br /> Test Location me <br /> - $ t .- <br /> 4. ❑ SANITATION PERMIT /� <br /> C+�' <br /> Job-Address/Location y h <br /> Owner d <br /> ❑ ESSPOOL 4LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> SEPTIC TANK <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR LJ OTHE <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June:30, 19 <br /> Type Construction t Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location � <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> 'SIZE: <br /> 9'SIZE: ❑ Less Than 1,000 Sq. Ft., }❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 r les regulatio s o th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Feels DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January i &Received By January 37 ❑ July 1 &Receiv REMITd By ulyf31 <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> - DATE DATE REMITTED AMOUNT <br /> drL4 — <br /> FEE <br /> LESS . <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER d <br /> OTHER <br /> Date Receipt No. - Permit No. <br /> Received by <br /> lssu nce Da Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />