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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> A (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 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) MoDonal d Sent,j c & BnokhnP Address 4645 911 r71-Pt,h LanP. <br /> c Owner T. R. McDonald Address Same <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 133679 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information G1 <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (fOR EACH VEHICLE) U <br /> For July 1,_ June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 3 <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 i <br /> Job Address/cation <br /> Owner — Address <br /> ,SEPTIC AU ❑ C SPOOL ❑ LEACHING FIELD 14 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW EPAIR ❑ 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 a <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served 1 <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/Mti. <br /> i <br /> r <br /> hereby certify that I have prepared this application and that the work will be done in accordance wit n Joaqu County <br /> ordinances, state laws, a rules regulations San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Ir <br /> .y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> EASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT _ <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1,59 q -7 y <br /> Received by Date Receipt No. Permit Na. Issuance lbate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />