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k -Applications Will Be Processed When Submitted Properly Completed:Be Sure To Sign The Application. <br /> APPLICATION <br /> f _ s (For Non-Transferable, Revocable, and Suspendable) .. <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> k LIQUID WASTE <br /> Appl icatiori i h reby Tyeo c rLy o?us4ness In thV jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Cuona 1 ep l C !an K JerV3 ce Address 4545 Hi 1 dreth Lane <br /> 4 Owner T. R. McDonald Address Same ; <br /> 1 Firm Partners, Addresses and Telephone Numbers n <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 997-4097 <br /> n Contractor Licence No. 308171 c[-� <br /> T. R. McDonald . Title Owner Date —� <br /> �Applicants Name (Print) - <br /> I Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> f For July 1, June 30, 19 Disposal Sites <br /> I Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic:nse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 " <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Lly <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �- <br /> a Test Location Test Date/Time -`- <br /> r. 4. ❑ SANITATION PERMITA� <br /> Job Address/Locat' n �/d`s( l <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACH 4G FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I, ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br />` No. of Units Equipment Storage/Cleaning Location(s) <br /> E <br /> i 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name II Where Certified <br /> Plant Location <br /> Plant Capacity I° No. Units Served <br /> r 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. T <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 d r wulationVe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &-Received By January 31 ❑ July_l Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> I BASE s; EXPLANATION _ AMOUNT DUE CHECKED -' <br /> DATE DATE REMITTED }�t/ AMOUNT <br /> FEE ' GS <br /> LESS <br /> i PRORATION <br /> I PLUS rlo <br /> PENALTY <br /> f <br /> OTHER <br /> OTHER - <br /> 6 �il!,- a ,V S <br /> Received by - Hate'1 Receipt No. Permit No. I suance ate Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />