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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 SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> +n Business Name (DBA) Address1dreth Lane <br /> i Owner T. R McDonald Address Same <br /> 4 <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 931-0497 Emergency Telephone.No. 957-4027 <br /> Contractor Licence No. 308171 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date00 <br /> Please check Applicable Category (1-7) and Fill in the Required Information O <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. ► -CAL. License No. CAL. Liccnse Renewal No. �l - <br /> Capacity : Gal.!Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD + <br /> For July 1, June 30, 19 ti "" <br /> No. of Vehicles Stored 10 Xe' - ~ <br /> No. of Chemical Toilets Stored <br /> 3. E] PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Nest Date/Time <br /> 4. ❑ SANITATION PERMIT 107 <br /> Job Address/ ocatio <br /> IV v "r s 1,-. 1 <br /> Owner s 11 PACKAGE PLANT (+ <br /> SEPTIC NK ❑ C SPOOLLEACHIN IELD AGUE PIT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER vl <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Type Construction DisposalSite—--w — --�+ <br /> No. of Units Equipment Storage/Cleaning Location(s) -t►1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 S <br /> Operator Name Where Certified <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., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> €� J <br /> I hereby certify that I have prepared this application and that the work will be done in accordance1wt� n Joaquin CountJI <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. llll <br /> APPLICANT'S SIGNATURE X007 <br /> /V! <br /> FOR DEPARTMENT USE ONLY <br /> l _ Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &\.e�iljl,Ai. J1 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLINGREM TTANCE $ AMOUNT DUE CHECKED <br /> DATE ATE k EMIT AMOUNT <br /> FEE T '] <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rg7za <br /> Received by - Date - Receipt No. errnit No. Issuance Date Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.�x 2009 STOC T N,CA 201- <br /> N- 1 9 a <br />