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r%Npuaauuns rrui merrocessea wnen Submitted ProperlyCompleted, Be Sure To Sign The Application. <br /> IT F APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> r ENVIRONMENTAL HEALTH-PERMIT <br /> _ LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Address <br /> 5 ,Hildreth Lane <br /> a Owner Address arae ' <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 9 4�- _ Emergency Telephone No.- 957-4027 <br /> Contractor Licence No. . 13 3 6 <br /> a P <br /> Name ame ( rint) T— R. McD0na . x Date <br /> � ldTitle< '- OWriD1' <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, -June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. 4 CAL. License Renewal N;. <br /> CapacityGal., Weights & Measures No.;, i <br /> Equipment Parking Address <br /> 2, ❑ PUMPER YARDS at y� § •* <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. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ ovation <br /> i <br /> :�z zoo <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT- ., <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -J ne 30, 19 <br /> Type Construction _Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - Where Certified. <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 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. <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, an rule nd re ulation f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> r <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY`-- `[] PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT ' <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY - <br /> OTHER .. ' <br /> P <br /> OTHER <br /> P f <br /> I <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered a <br /> - 'AIMUCANT—RETURN ALL COPIES TO: _ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bom 2009 STOCKTON,CA 95201 <br />