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V APPLICATION <br /> (Foy ..on-Transferable, Revocable,and Suspendable)` SEPTAGE <br /> .• '"`� ENVIRONMENTAL HEALTKPERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address_ fiLsS jli�E�7"L' 9 <br /> F Business Name (DBA) Mc 3onald L hildreth_�ane , <br /> z Owner T . R T Address r <br /> a <br /> L Firm Partners,Addresses and Telephone Numbers � 4{l77 <br /> aBusiness Telephone No. 9 7 -0497 7 Emergency Telephone Na. 4 <br /> Contractor Licence No. <br /> 41 <br /> Applicants Name (Print) Title Date <br /> FF <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., Calor) <br /> Serial No. <br /> CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Me s <br /> Equipment Parking Address ^ , <br /> 2. ❑ PUMPER YARD `v <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> I 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/Location <br /> Owner Address <br /> SEPTIC TANK P CESSPOOL LEAC NG FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 13TEMPORARY ' EW ❑ 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 /> 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 regulations of lo..San Joaquin Local ealth strict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT K PEH SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE eS- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 7 <br /> Received by Dale Receipt No. Per it No. issuance Date Mailed ? Deliv ed APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTOH AVE.,P-O.Box 2008 STO TON,CA 95201 - <br /> �r <br />