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Applications Will Be Processed When Submitted Properly Completed. Be <br /> �~~ <br /> APPLICATION . <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the Sa46o�gui H�Oc�adrethl Health 'sLaI1G <br /> Mc-c-mid Se tic Tank Service Address 44.77 <br /> rn Business Name (DBA) Same <br /> z Owner T R• McDonald Address <br /> 4 <br /> 0 Firm Partners, Addresses and Telehone Numbers Telephone No. ��7-4027 <br /> a Business Telephone No. �31-0497 Emergency p <br /> 305171 . <br /> ( <br /> L Applicants Name (Print) <br /> i Please check Applicable Category (1-7)and Fill in the Required Information <br /> I 1. ❑.PUMPER V%EHICLE PERMIT:REGISTRATION (FOR E- ;W_ ICLE) <br /> �- t, <br /> For July <br /> June 30, 19 € Disposal Sites <br /> ,F <br /> j Description(Make/Yr-, Color) n CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Gal.,Weights &Measures No. � <br /> Capacity <br /> ' <br /> Equipment Parking Address <br /> F 2. ❑ PUMPERiYARD <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.C.E. No. <br /> R.S. or R.C.E. Name`- -"` "" ' <br /> I t I Test Date/Time <br /> Test Location ) <br /> 4. ❑ SANITATION PERMIT s,, <br /> Job Address/Location ; <br /> Owner ddress <br /> SEPTIC TANK CESSPOOL -L=EACHIN -IEL6.� EEPAGE PIY 13 PACKAGE PLANT <br /> PERMANENT 11 TEMPORARY NEW <br /> REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Sl'ite <br /> No, of Units Equipment Storage/Cle}ning Location(s) <br /> 6. ❑ PACKAGE TRATMENTiiPLANT. For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> t Plant Location <br /> Plant Capacity;y. _ No. Units Served <br /> 7. ❑.LAUNDRY For Julyk1, June 30, 19 <br /> j, SIZE: 0 Less,Than 1,004-Sq. Ft-, El More Than 1,400 Sq. Ft. <br /> t ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> H <br /> i <br /> I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> f <br /> ordinances state laws a d rule nd re ulat' S the San Joaquin Local alth District <br /> APPLICANT'S SIGNATURE, - II <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE EACH 13 January 1 &Received By January 31 July 1 &ReceivedREMITury 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> €. BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE L4 4 <br /> I. <br /> LESS. <br /> PRORATION <br /> PLUS r + <br /> PENALTY <br /> OTHER <br /> t - <br /> a <br /> R OTHER <br /> 660 65,4 permi6o 65, Q issuance7 Date Mailed Delivered <br /> Received by Date Receipt No. <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.DO 2005 STOCKTON,CA 952 <br />