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I When Submitted Properly Completed. Be SureToSignTneAppucauon. <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl cation is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />`r Business Name (DBA' ) MC Address �i 6- <br /> 45 <br /> i Owner T. R. MCDOA Id Address <br />_Q <br /> ,Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. 931-0497 Emergency Telephone No. (~ <br /> Contractor Licence No. 308171 I # <br /> Applicants Name (Print) <br /> T. R. MCDo lald Title Date <br /> Please check Applicable Category (11-7) and Fill in the Required Information QT4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR,EACHVEHICLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) 'I CAL. Llccnse Renewal No. <br /> Serial No. CAL. License No. 4 <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I <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.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test LocationTest Date/Time <br /> ri V S <br /> 4. ❑ SANITATION PERMIT _ p <br /> Job Address/Location I <br /> Owner Address <br /> SEPTIC TANK CE POOL LEACHING FIELD SEEPAGE PIT ❑ PA KA E PLANT <br /> 11 PERMANENT ❑ TEMPORARY NEW 1:1 REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19- <br /> Type <br /> 9 Type Construction t Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> .6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 y" Where Certified <br /> Operator Name ai <br /> Plant Locatiori <br /> - No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 'a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 4 <br /> work will be done in accordance with San Joaquin County <br /> I hereby certify that i have prepared this application and that thew <br /> ordinances, state laws, an rules an gulati s of the S J aquin Local Health istr' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY *. <br /> F . <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &ReceivedBy31 <br /> I BILLING REMiTTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT F <br /> � r o <br /> 4 <br /> FEE <br /> y LESS - - - <br /> PRORATION <br /> PLUS <br /> f PENALTY <br /> OTHER <br /> )THFR <br /> (e Y03 <br /> N Date ReceiptlNo. - Permit No. _ Issuance Date Mailed Delivered <br /> ived by .......,"„�: `- "i. <br /> 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br /> •-jPClCANT—RETURN ALL COPIES TO:: ENVIRONMENTAL HEALTH PERMIT/SERVICES' E4 i <br />