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Applications Will Be Processed When SuAPPLICATIO1VCompleted. Besure <br /> h <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAG� <br /> r� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the SWdRggU n opal H al District <br /> McDonald Se ti c ryTank Service Address <br /> 44ffjj Ilii aret i bane <br /> -Business Name (DBA) address Same, <br /> a Owner <br /> CQOnald <br /> J Firm Partners, Addresses and Telephone Numbers 957-4027 + <br /> 9 �_ Emergency Telephone No. <br /> M <br /> Business Telephone No. — <br /> Contractor Licence No. 30 Owner Date <br /> Applicants Name (Print} <br /> d Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information _0 5 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t f <br /> For July 1, June 30, 19 <br /> Disposal Sites <br />` Description(Make/Yr., Color) CAL. Lic`ase Renewal No. µ <br /> Serial No. CAL. License No. 4 1 <br /> Gal.,Weights & Measures No. '� 1 <br /> Capacity i x <br /> Equipment Parking Address <br /> k 2. ❑ PUMPER YARD !i <br /> For July 1, June 30, 19 Y TN <br /> ` No. of Vehicles Stored �. _._. t , r <br /> No. of Chemical Toilets Stored <br />�. 3. ❑ PERCOLATION TEST <br /> t R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name ; <br /> _ + Test Date/Time Test Location -��.,.w•� -----^ <br /> 4. 11 SANITATION PERMIT I f <br /> Job Address/Location Address ' <br /> r" Owner ❑ PACKAGE PLANT <br /> 11 SEPTIC ANK ❑ CESSPOO ❑ LEACHING-FIELD;_ ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORA ❑ NEW REPAIR V.-L.J <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 fI -1 � 1 <br /> ' <br /> i Type Construction " Disposal Site ' <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> June 30, 19- i <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1,- Where Certified <br /> Operator Name f <br /> ( Plant Location <br /> t � No. Units Served <br /> Plant Capacity t <br /> 7. ❑ LAUNDRY For July.1, -June 30, 19 <br /> Si C300 Less Than 1,0Sq. Ft., C3More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. t <br /> 6.. <br /> ^Y <br /> t the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and tha <br /> ordinances, State laws, and rulesa d regulations of t San Joaquin Local He th District. <br /> APPLICANT'S SIGNATURE i - <br /> . �1,� Via * <br /> FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due' ❑ ANNUALLY <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE <br /> CHECKED <br /> BASE DATE DATE REMITTED AMOUNT <br /> ( LAS r <br /> FEE <br /> LESS <br /> PRORATION 5 <br /> PLUS <br /> PENALTY 1� <br /> !I{ OTHER r I <br /> f <br /> OTHER <br /> 623olD 116 Ba <br /> No. Permit No. Issuance Date Mailed Delivered <br /> Receipt <br /> Received by - Date 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />