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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 <br /> SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby rr�ia a to car qn busines$In t e jurisdictional area of the o{q I n, c I Health strict <br /> y Business Name (DBA) $ZCDOnal Sep ZC T111K ErVZce Address � J Z� retn Lane <br /> a Owner T. R. McDonald Address Same - <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-4027 n <br /> Contractor Licence No. 08171 -_�- <br /> �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) �9 <br /> For Jul 1, June 30, 19�. i, ; <br /> July 4��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 <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.G.E. No. <br /> Test Location i Test Date/Time <br /> CA <br /> 4. ❑ SANITATION PERMIT _ # '*+ O <br /> Job Address/I nratior,Address/II152 `0 <br /> Owner f Address t <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD L�SEEPAGE PIT PACKAGE PLANT C <br /> PERMANENT ❑ TEMPORARY . NEW ❑ 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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity M No. Units Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19""x^^'—""^^^—' <br /> SIZE, ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 11 D", <br /> CLEANING, Chemicals Used/Amount/Mo. <br /> I 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, and4r`ules-and regulations of the oaquin Local Health District. 4 <br /> APPLICANTS SIGNATUREXe <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LY PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> QJ <br /> FEE S v07 47� <br /> LESS > < <br /> PRORATION. <br /> PLUS <br /> PENALTY S <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu rice Date Mailed DV7. <br /> APPLICANT 009 ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 ST95201 <br />