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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ... <br /> " '- (For Non-Transferable, Revocable, and Suspendable) <br /> AENVIRONMENTAL HEALTH PERMIT SEPTAGE I <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> aBusiness Name (DBA) McDonald Septic Tank Service Address 4.645 Hildreth Lane <br /> Owner 1. MCDo iald <br /> Firm Partners, Addresses and Telephone Numbers Address ga�Ea <br /> r a Business Telephone No. 931-049.7 <br /> J Contractor Licence No. 3O$� ]� Emergency Telephone No. 957-4027 <br /> Q <br /> L Applicants Name (Print) T. I<.. A1CDonald <br /> r Please check Applicable Category Title 0C�7ner Date <br /> g ry (f-7}and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J" <br /> ForJuly 1. June 30, 19 *- <br /> Serial <br /> Disposal'Sites '*- <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> tCAL. License No. CAL. Liccnse Renewaf No. <br /> Capacity <br /> � Gal„ Weights 8, Measures No. J <br /> j Equipment Parking Address <br /> 2• ❑ PUMPER YARD <br /> r P <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 <br /> Test Location R.S. or R.C.E. No. <br /> 4• ❑ SANITATION PERMIT Test Date/Time.t <br /> Job Address/Location <br /> d <br /> Owner <br /> SEPTIC TANK CESSPOOL dress lI <br /> �NEACHING FIELD SEEPAGE PIT TD PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY <br /> 5. `❑ CHEMICAL TOILETS For July 1, -Ju Nap g ❑' EPAIR-= '�❑ 6THER (� <br /> Type Construction fDisposal Site E <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> s• ❑ PACKAGE TREATMENT PLANT For JulyT1, June 30, 19 <br /> Operator Name <br /> Plant Location where Certified �� <br /> Plant Capacity ` r U, <br /> No. Units Served <br /> 7. ❑,LAUNDRY �For Ju-)y f, -Ju e 90, 1-9'1-'7!Q �' ' i $%J <br /> SIZE: ❑ Less Than 1,000 S Ft., ❑ <br /> Sq. More Than 1.600cSq, Ft. I: <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. j 01 <br /> i <br /> �A l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sar: <br /> ordinances, state laws, and rules d regulations a San Joaquin LocalHJoaquin County <br /> eal h District. <br /> APPLICANT'S SIGNATURE X j <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE <br /> ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received ey July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE LI -S AMOUNT r <br /> LESS <br /> PRORATION , c D <br /> PLUS 1� <br /> PENALTY <br /> c� <br /> OTHER ' <br /> r <br /> OTHER <br /> O q x <br /> Received by Date Receipt No. <br /> Permit No, <br /> -APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SEAvICES Issuance Date r Maifed ivered + <br /> — y 1601 E.-HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA-95201 + <br />