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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 basin ss n the jurisdictional area of the San JQaquir? opal H alth District <br /> rn Business Name (DBA} McDonald Septic Tan Siervi.ce Address 4645 Hl�dreth Lane i <br /> I.- <br /> Owner. T. R. McDonald Address toC ton, d t <br /> I <br /> Firm Partners, Addresses and Telephone Numbers <br /> 57-4027 <br /> a Business Telephone No. 3Q8 �.7 Emergency Telephone No. g <br /> Contractor Licence No. _ <br /> Applicants Name (Print) T.R.. McDonald Title Owner Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 4i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL'Gcc se-Renei_ai No`"`""`"""'y" . <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address _ I <br /> 2. ❑ PUMPER YARD <br /> For July 1, .`June 30, 19 - � <br /> No. of Vehicles Stored >4 r $ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t►`�r. <br /> t <br /> R.S. or R.C.E. Name . S._or,R.C.E. No.m ` ,. .�..., �.�......�.... '�, <br /> Test Location �' st Date/Time;° t <br /> 4. ❑ SANITATION PERMIT ` <br /> Job Address/L cation E1 <br /> caner dress <br /> SEPTIC TANK ❑ CESSPOOL LE CHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW -1 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - 'June 36, 19 <br /> : Type Construction Disposal Site •� # <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,.19 <br /> Operator Name t�, Where Certified - <br /> Plant Location <br /> r 9 <br /> Plant Capacity No- Units Served y I <br /> 7. ❑ LAUNDRY For July 1, -June 30, 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 applicati d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ales regulations e 4n Joaquin Local He h District. <br /> APPLICANT'S SIGNATURE,' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January S &Received By January 31 ❑ July 1 &Received By July 31 <br /> Z REMIT <br /> BILLING REMITTANCE $ ' <br /> EASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> t' FEE <br /> a <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY 14 <br /> OTHER1 <br /> OTHER - <br /> � _ t <br /> Received'by :Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O:Box 2009 -STOCKTON,CA 95201 <br />