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Applications Will Be Processed When Submitted Properly Completed. Be SureTO signTneAppimauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> f } <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F <br /> Business Name (DBA). MCDOnal d Septic Tank Service Address 4645 Ali l dreth Lane <br /> VT R McDonald Address Same <br /> a Owner <br /> 70 Firm Partners, Addresses and Telephone Numbers 957'407 <br /> a Emergency Telephone No. <br /> a Business Telephone No. — - <br /> Contractor Licence No. 108171y <br /> LApplicants Name (Print) Title . Qw.ner Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. '❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July t- June 30, 19c Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. Liccnse Renewal o. . <br /> I Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> I For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST V <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location { <br /> Owner - P ess U <br /> *_SEPTIC TANK CE POOL �;LEACHING F LD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARYNEW 13REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J ne 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> C. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <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., ❑ More Than 1,000 Sq.Ft. ' <br /> I. ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that.l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rule d re ulations of an Joaquin Local Health Dis ct. <br /> 4 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT.USE ONLY <br /> f " <br /> I -Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I � 's <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> E <br /> r OTHER <br /> OTHER <br /> © �Q�1 � Oil, loIgo <br /> Received by ,Date - Receipt No- Permit No 1ss ance Date filed Delivered <br /> 'APPLICANT--RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.0,Box 2009 STOCKTON,CA 95201 <br />