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. . .. <br /> lications Will Be Processed When Submitted Properly omp e <br /> Appytea <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL WASTE <br /> HEALTH PERMIT <br /> LIQUID <br /> Application is hereby made to carry on business in the jurisdictional area of the Sanddress 64�inHl f Healthal District lt2 212 <br /> y Business Name (DBA) eDOnald Septic Tank Serv4645ice AHildreth Lane 95212 <br /> a Owner <br /> T , R, 1�ieDonald Address <br /> J.Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. t <br /> R. Business Telephone No. <br /> 931-0497 <br /> Contractor Licence No. 308171 Owner Date <br /> aT. R. NICDonald Title <br /> LApQlicants Name (Print) vku <br /> Applicable Category(1-T) and Fill in the Required Information <br /> Please check <br /> 1. RATION (F <br /> ❑ PUMPER VEHICLE PERMIT REGISTn Disposal <br /> aCSEHiCLE) <br /> Sites <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No, <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address , <br />{, 2, ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ' t\ <br /> No. of Chemical Toilets Stored v] <br /> 3. ❑ PERCOLATION TEST i R.S. or R.C.E. No. <br /> R.S. or R.C.E. Namej Test Date/lime <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location Address <br /> Owner LEACHING FIELD dX SEEPAGE PIT ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSP L ❑ REPAIR ❑ OTHER <br /> I ❑ TEMPORARY NEW <br /> A PERMANENT <br /> k 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 10isposal Site <br /> k Type Construction <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 I No. Units Served <br /> k Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 3Q�19 <br /> SIZE: ❑ Less Than 1,o00 Sq. Ft., ❑ More Than 1,000 Sq. Ft, <br /> 11DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i ion and that the work will be done in accordance with San Joaquin County <br /> �. I hereby certify that I have prepared this applicat <br /> ordinances, state laws, and rule an regal sof the San Joa in Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> I <br /> i FOR DEPARTMENT USE ONLY <br /> PER SITE _ EACH ❑ anuary 1 &Received By January 31 ❑ Suiy 1 &Received <br /> ByI July 31 <br /> PER UNIT <br /> P <br /> Fee Is Due: ❑ ANNUALLY ❑ REM T C $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION T <br /> BILLING L �'REMITTED AMOUNT <br /> FEE <br /> r <br /> LESS <br /> PRORATION •, <br /> PLUS f i <br /> PENALTY <br /> j OTHER <br /> I <br /> OTHERir <br /> Receipt Na <br /> S I suanc Datel Mailed Dells d y 7 <br /> Permit No. STDG TON,C <br /> Received by Date 16oi E:HAZELTON AVE.,P.O.Box 2009 ' 9 01 <br /> f=' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />