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n -,Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicjition., <br /> APPLICATION <br /> .(For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT i r. SEPTAGI <br /> i LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r' y Business Name (DBA) Address_ 4645 H.i.ldreth lane <br /> i Owner T R. Mcl)n-na 1 ri Address Same <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> M a Business Telephone No. 931 .-Q497 Emergency Telephone No. 957-4097 <br /> Contractor Licence No. 308171 - <br /> L Applicants Name (Print) T. R. McDonald Title ��pT ', Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> ' 1. ❑ PUMPERMEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE), <br /> For July 1, June 30, 19'x ` Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. - ,CAL.License No. a CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> I. Equipment Parking Address a <br /> ! 2. ❑ PUMPER YARD i t <br /> For July 1, June 30, 19 -- -- <br /> No. of Vehicles Stored_ h, <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT '.-a - C4 <br /> Jab Address/Locatio <br /> Owner Address <br /> ❑ SEPTIC ANK CESS OOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t Type Construction r Disposal Site <br /> No. of Units 'u Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f <br /> " <br /> Operator Name !i Where Certified <br /> _- <br /> Plant Location ' <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -'June 30, 19- <br /> SIZE: <br /> 0, 19SIZE: ❑ Less Than_1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft. <br /> k ❑ DRY4CLEANING, Chemicals Used/Amount/Mo. 3 <br /> .I <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 regulation he San Joaquin ocal ealth District. <br /> lo <br /> I APPLICANT'S SIGNATURE X I t <br /> f! <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 'i ❑ PER UNIT PER PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - <br /> REMIT <br /> F BILLING REMITTANCE $ <br /> BASE EXPLANATION .%,DATE r .DATE REMITTED AMOUNTDUE - AMOUND 3. <br /> FEE :_ ' 1 i <br /> LESS 914> <br /> PRORATION -. "", ,-, 161 E t _ <br /> PLUS <br /> PENALTY <br /> r OTHER <br /> k OTHER <br /> ~- <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1801 E.HAZELTON AYE-,P.O.Box 20U9 STOCKTON,CA 952111 <br /> APPLICANT—RETURN ALL cRPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> r , <br />