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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 /> Business Name (DBAj McDonald Septic TankService __Address 4645 Hildreth Lane , <br /> a Owner T. R. McDonald Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 931-0497 Emergency Telephone No. 7--4027 _ <br /> Contractor Licence No. 308171 d <br /> Applicants Name (Print) T. R. McDonald Title _ Owner :...: Date (-- <br /> Please check Applicable Category (1-7) and Fill in the Required Information O <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For July 1, ' Iune'30, 19 Disposal Sites <br /> Description(Make/Yr., Color) � �� N <br /> Serial No. CAL. License No. � - p CAL."L1c nse R *4e'l No--' <br /> Capacity Gal., Weights & Measures No, I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No.Tof;Chemical Toilets Stored <br /> 3. ❑"IPERCOLATION TEST <br /> I <br /> R.S.Ior_'R:C.E. Name. R.S. or R.C.E. No. <br /> Test ffocation Test Date/Time / <br /> 4. ❑ SANITATION PERMIT <br /> Job'Address/ ocation <br /> • r <br /> Owner, '', Address9_1)yz�o' <br /> ; <br /> �§'EP-b.C-TANK ff CESSPOOL 'LEACHINGFIELD ❑— PAGE-PITDYPACKAGE PLANT" <br /> PERMANENT ❑ TEMPORARY ❑ NEW 13�REPAIR ❑ OTHER <br /> El <br /> 5. CHEMICAL TOILETS,�For,July 1 z,June 30, 19 p <br /> Type Construction > ' ' DisposSII Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> F. <br /> 6. 0 .,1� <br /> PACKAGE TREATMENT PLANT For Jul y'll, -June 30, 19 � <br /> Operator Name `s Where Certified <br /> Plant Location <br /> Plant,Capacity No. Units Served i <br /> a <br /> 7.-'El LAUNDRY For July. 1, -June 34,_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 applicatio��d'that the'work will be%-done In.accordance with San Joaquin County <br /> #, ordinances; state 1 s, and'' `� g f ns ori" he San Joaquin cal alth Dlsthdt.:( y <br /> APPLICANT SSIGNAT,L')REX` "� ' <br /> wi S <br /> FOR DEPARTMENT-USE ONLY <br /> Fee IS DUe: 0-1, <br /> • NNU L d PER UNIT ❑APER SITE.._ ❑'EACH ❑-January 1 &Received By January 31 ❑ July I &Received BY Y Jul 31 • <br /> _ BILLING REMITTANCE $ _ REMIT <br /> BASE I.EXP,LANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT j <br /> v.45 L <br /> LESS ret l r .r <br /> PRORATION <br /> PLUS �a,T <br /> PENALTY <br /> OTHER <br /> OTHER4w = .. <br /> Received by' � Date Receipt No.- Permit No. k Issuoince Date e D'eliverki <br /> r.. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. 009 STOCKTON,CA 95201 - <br />