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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 Suspendabie) <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 /> W Business Name (DBA) McDonald Septic Tank Service Address 4545 Hildreth Lane <br /> iowner T. R. McDonald Stockton Ga 95212 <br /> r"- <br /> Firm Partners,Addresses and Telephone Numbers <br /> - m'Business Telephone No. 931-4497 Emergency Telephone No. 957-4027 <br /> j Contractor Licence No. . 308171 <br /> Applicants Name (Print) T. R. McDonald Title owner Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information n <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR,EACH VEHICLE) `• �. �] <br /> For July 1, June 30,'19 Disposal Sitest_ �Z <br /> Description(Make/Yr. Color) b- <br /> Owner's Name <br /> 26 <br /> cense-N <br /> —Address- _ <br /> Equipment Parking Address <br /> `12. ❑ PUMPER YARD <br /> For July 1, June 30, 19 00 <br /> No:of Vehicles Stored ,•f/ + <br /> No. of Chemical Toilets Stored <br /> 3. ❑"PERCOLATION TEST <br /> R.S. or R.C.E. Name �� R.C.E. No. <br /> Test Location ... 1 <br /> Test Date/T� a <br /> 4. El SANITATION PERMIT t <br /> Job Addre Location <br /> Owners I " Address <br /> r �SEPTfC TANK 11 CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> [ ❑ PERMANENT ❑ TEMPORARY �J, <br /> NEW e ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - e 30, 19 �l <br /> k Type Construction Disposal Site tit <br /> No.of Uri its Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 a <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 /> 3 ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F f <br /> I hereby certify that I have prepared this application and that the work will be done in ac ante with San Joaquin County <br /> i ordinances, state laws, an rul amdlatgiof the San Joaq n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f <br /> FOR DEPARTMENT,USE ONLY i <br /> �' <br /> Fee is Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By Juiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> :AMOUNT DUE CHECKED J <br /> _ - DATE GATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ti <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> ` OTHER <br /> wy k <br /> I <br /> H b - i <br /> Received by - Date Receipt No. Permit No- ssuance ate Mailed Delivered <br /> - <br /> APPLICANT—RETURN ALL COPIESrTO - ENVIRONMENTAL-HEALTH PERMIT/SERVICES 1601E HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br />