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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 /> r <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <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 (DBA) McDonald. Septice .wank SerV i Cf, Address 4645 1j1dreth Lane <br /> a Owner T. R. MCDonald Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Q.a Business Telephone No. 1-0497Emergency Telephone No. 957,4027 <br /> Contractor Licence No. <br /> L Applicants Name (Print) 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 `+, <br /> Description(Make/Yr., Color) �- }{ " ;` �' s` :h I <br /> Serial No. CAL. License No. y`��"®`• CAL._Liccnse Renewal-No --— t <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD N <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored tt t t <br /> 3. ❑ PERCOLATION_TEST •� s ' <br /> R.S. or R.C.E. Name – "-""�`�"`*" R.S 'or R.C.E. No. t <br /> Test Location Test Date/Timeltf' 1 a <br /> f <br /> 4. 11 SANITATION PERMIT p <br /> Job Add ress/Lp cation <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD -w'D-SE€PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. [],CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction € Disposal Site 99 <br /> No.of Units, _ Equipment Storage/Cleaning Location(s) <br /> E <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where'Certified <br /> Plant Location x ' <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. �" g <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 <br /> All <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, d r nd regulation the San Joaquin L cal alth District. <br /> APPLICANT'S SIGNATURE X ° <br /> ;; <br /> FOR DEPARTMENT USE ONLY t <br /> Fee IS Due: ❑ ANNUALLY PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &.Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT' <br /> BASE EXPLANATION PATE DATE-"' REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS r_ _ <br /> PENALTY �(�rrk <br /> � <br /> OTHER <br /> OTHER <br /> -7 <br /> Received by Date Receipt No. Permit. o, - Issuance Data Mailed DeliVered <br /> :APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.Ha2ELTON AVE..P.O.Bo=2009 STOCKTON,CA 95201 <br /> ij' <br />