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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,I� <br /> I APPLICATION <br /> _ '' • '= (For Non-Transferable;Revocable,and Suspendable) ¢{• <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE ' <br /> 'LIQUID WASTE � <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local He � i <br /> SlnesS Name IDEA)_ MCDO_ TY3]•[i SgRti C Tank' G,ar ; Address 1 f <br /> t wner_ T. R.4 McDonbld Address <br /> A am <br /> 3.Firm Partners,Addresses and Telephone Numbers <br /> a Business Telephone No.- 9 31-0'1+9 7 Emergency Telephone No.—9 5 1• <br /> Contractor Licence No, 308171 <br /> 702 7 <br /> L Applicants Name(Print) T- R A McDona l d Title _ •m y Date <br /> Please check Applicable Category(1-7)and Fill In the Requlme Information <br /> i. 0 PUMPER YEH�YCLE PERMIT REGIShATIONr(POR'EACH VEHICLE) <br /> Q <br /> > a E) <br /> For July l'; 'v^Juhe 30;19 '�'� '^ <br /> ti .� Disposa�Sites <br /> Description(MakelYr. Color) - <br /> Serial No. <br /> CAL License No. .,. <br /> CAL.License Renewal No. <br /> Capacity Gal.,Weights 3 Measures No. <br /> Equipment Parking Address -_ <br /> 2. 0 PUMPER YARD e <br /> For July 1, June 30•;19 <br /> No,of Vehicles Stored <br /> NO. of Chemi6i Toilets Stored <br /> 3. 0 PERCOLATION TEST . <br /> R.S,or R.C.E..Name It <br /> Test Location R.S.or R.C.E.No. <br /> t t <br /> 4• 0 Test Date/Time <br /> SANITATION PERMIT QO yZ r <br /> Job Addreas Location !/ ,i <br /> Owner ' <br /> Address <br /> i^EPTIC TANK ❑ CEdi OOL LEACHING FIELD 0 SEEPAGE PIT PACKAGE PLANT _! <br /> PERMANENT 0 TEMPORAkY EW 0 REPAIR D.OTHER - <br /> 5. CHEMICAL TOILETS For July 1,.Jun 30,.19 'fid <br /> Construction J? � - Disposal Site Q . <br /> of Units" - Equipment StoragelCleaning Locations) r <br /> O PACKAGE TR£ATMENT PLAINT For July 1,-June 30, 19 a Q <br /> Operator Name. 77tt f <br /> Plant Location Where C�rtified N I <br /> �- . <br /> Plant Capacity d No. Units Served r <br /> 7. 0LAUNDRY For July 1,-June 30; 19 <br /> SIZE: /0 Less Than 1,000 Sq. FL31 0 More Than 1,000 Sq a�Ft,.` - <br /> 0 DRY CL•1ANING,Chemicals USED/AmOUnt MO. 1 i1 <br /> f�L <br /> �1 hereby certify that I haland prepared this application a d that the work will be done in accordance with San Joaquin County <br /> ulation _ <br /> ordinances,state Taws,and r las egs of Joaquin Local Hea h Di 'ct. <br /> r <br /> APPLICANT'S SIGNATURE X a !" � <br /> r +1 <br /> d <br /> -- r . a. <br /> W. <br /> - _ 'FOR DEPARYMENT USE ONLY <br /> Feels'Due:❑ ANNUALLY, I] PER UNIT ERAll F`'f' �.{qOH <br /> �. January 1 a Recelvetl ey Jenuery 31 ❑JUIY 1 8 Receive0 By JUI 31 <br /> BASE F EXPLANATI .µ, BILLING REMITTANCE $ PMIT <br /> r< `• Ate{{ DATE REMITTED AMOUNT DUE CHECKED <br /> ,.,,;,-�„ �• AMOUNT <br /> + 1 <br /> LESS y ` <br /> PPORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ...... <br /> r✓ a I r <br /> Receiv¢tl11'bY Date J�rL Receipt No. Pe,mil NO. <br /> AliPLICANTRETURM ALE'COPIES TO: ENVIRONMENTAL HEALTH PERMILSERVICES 1 ISsuanee Date Mailetl Deb <br /> `p, fiat E.HAZELTON AVE.,P.O.am 2009 STO YON,CA f� . <br />