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..� ...:.s=-� i-—••.r,:-,�.� -ger �- +,#• <br />� <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure o <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH_ PERMIT <br /> j LIQUID WASTE —� <br /> i Application is hereby madelto carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> rn Business Name (DBA) <br /> a Owner T R.M D 1d Address <br /> 1 u Firm Part'ners, Addresses and Telephone Numbers 957-4027 <br /> CL Business Telephone No. 931-0497 Emergency Telephone No. <br /> Q - 308171 <br /> Contractor Licence No. Owner, Date <br /> Applicants Name (Print) T. R. McDonald Title <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) CAL. License Renewal No. . <br /> F' Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address r <br /> 2. ❑ PUMPER YARD <br /> i <br /> For July 1, June 30, 19 <br /> ` No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.G.E. No. <br /> I R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> f 4. © SANITATION PERMIT € m <br /> Job Address/Location a <br /> Owner Address <br /> D CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT G} <br /> ❑ SEPTIC A ❑ OTHER <br /> ❑ PERMANENT ❑.TEMPORARY ❑ NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> I Plant Location <br /> No. Units Served � <br /> r Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 --57 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> { <br /> I hereby certify that 1 have prepared this appy nand that the work will be done in accordance with San Joaquin County <br /> ` ordinances, state laws, and rules and re ulatio oft a San Joaquin Local ealth District. <br /> APPLICANT'S SIGNATURE X p! <br /> FOR DEPARTMENT USE ONLY <br /> - PER SITE ❑ EACH, ❑ January 1 &Received By January 31 E] Juiy 1 &ReceivedByJuly 31 <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT 13 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> aASE EXPLANATION DATE DATE REMITTED AMOUNT. <br /> FEE <br /> LESS <br /> - PRORATION <br /> PLUS •' Al - <br /> PENALTY <br /> OTHER 7t <br /> OTHER <br /> r Permit No- Issue ce Da Mailed Delivered <br /> Received;by Date 1 Receipt No. <br /> 1601'E.HAXELTON AVE.,P O..Box 2009 STOCKTON,CA 95201 <br /> APPLIbANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES - <br />