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—`Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPtAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> . Business Name (DBA) Address L#jL�Sildreth Lance <br /> a Owner .. T.R. McDoT�a d Address Same "1 <br /> Firm Partners, Addresses and Telephone Numbers c� <br /> ILBusiness Telephone No. 931-0497 11 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 848171 <br /> LApplicants Name (Print) T.R. MCDonild Title JD r 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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 1 <br /> Job Address/Location <br /> Owner r� Address <br /> - <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY A NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _ r1�l Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 d <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 /> h� <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 regul ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -4-316051-7 <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 Jusy 31 <br /> BILLING REMITTANCE $ REMIT y <br /> BASE EXPLANATION' AMOUNT DUE CHECKED <br /> DATE DATE REMITTED f <br /> 9-31 <br /> AMOUNT <br /> FEE �/V <br /> LESS <br /> PRORATION 1 ' <br /> E <br /> PLUS <br /> PENALTY <br /> OTHER rr <br /> OTHER f <br /> Received by Date Receipt No Permit No: Issuance ate I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2D09 STOCKTON,CA p#-_ <br />