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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application'. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT J ''SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District r <br /> ,F Business Name (DBA) MCT)nnAl d SPnt-ic Tank Service Address 4645 H ildreth Lane ' <br /> c Owner r,�R McDo aI r1 Address Stockton Ca 95212 <br /> J Firm Partners, Addresses and Telephone Numbers t <br /> a, Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 3C) 4 <br /> L Applicants Name (Print)T_ R_ McDonald __ Title Owner Date <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. CAG. Lioz.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 <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 w ,( <br /> Job Address/Lo ation <br /> ,Zcaner t Address <br /> SEPTIC TANK 1:1 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER d <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Jne 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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br />,4 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 acc&dance with San Joaquin County <br /> ordinances, state laws, and rules and regulatio f the San Joaquin Local Health District. <br /> 'f <br /> APPLICANT'S SIGNATURE X l� <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 /> REMIT <br /> BASE EXPLANATION KILLING REMITTANC AMOUNT DUE CHECKED ' <br /> DATE ATE RE 1 TED' AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER F _ <br /> OTHER T_ <br /> Received by - Date - -Receipt No. Permit No. ssua a Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ AVE.,P.O.A—2009 STOCKTON,CA 95201 <br />