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Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign ineKppur-auail. <br /> r -" APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District #>., <br /> MC DONALD SEPTIC TANK SERVICE Address 4645 HILDRETH LANH <br /> F Business Name (DBA) SAME <br /> z Owner T. R. McDONALD Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers 957-4027 <br /> 1 n Business Telephone No. 931-0497 Emergency Telephone Na. <br /> a <br /> Contractor Licence No. 308171 Owner Date <br /> Applicants Name (Print) T. R. MC DONALD Title <br /> Please check Applicable Category(1-7)and Fill In the Required Information d <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) q <br /> For July 1, June 30, 19 Disposal Sites ' <br /> Description(Make/Yr., Color) - - CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> i Capacity Gal, Weights &Measures No. <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 n <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. - <br /> R.S. or R.C.E. Name - <br /> *-- Test Date/Time " <br /> Test Location t <br /> 4. ❑ SANITATION PERMIT <br /> Job Addres ratio <br /> Address <br /> Owner <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT n l <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPt AIR 11 OTHER <br /> i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locati n(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> Where Certified <br /> Operator Name , <br /> „e, r <br /> I Plant Location + <br /> No. Units Served <br /> Plant Capacity ` <br /> 7. ❑ LAUNDRY For,July,1, -June 30, 19 � <br /> 4 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 application and that the work will be done in accordance with San Joaquin County , •" <br /> ordinances, state laws, and rules an egulations of e n Joaquin Local Health District. , <br /> E <br /> APPLICANT'S SIGNATURE X <br /> r t <br /> i e FOR DEPARTMENT iUSE ONLY ( * <br /> Fee Is Due: C1 ANNUALLY. ❑ PER UNIT IJ PER SITE ❑ EACH ❑ Januarys &Received By January 31 © July 1 &Receiv REMIT <br /> d By uIy 31 <br /> BILLING REMITTANCE _ $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION, DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> F PRORATION <br /> PLUS l' <br /> { PENALTY <br /> OTHER ._ <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. ssuanc Dat Mailed Delivered <br /> k - ;APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2 OW STOCKTON,CA 95201 <br />