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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> RC1 (For Non-Transferable, Revocable,and Suspendable) <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 /> F Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildreth Lane <br /> z Owner T. R. McDonald Address same <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 343171 <br /> a <br /> L 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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ;a <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST + <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 Addres Locatio S <br /> Owner y Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 171 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-;June 30, 19 _k <br /> Type Construction Disposal Site a <br /> No. of Units 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 i <br /> 7. ❑ LAUNDRY For July 1, -June 30, t� <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 and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ang jules regulations o M San Joaquin Local HeAItI2 District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION D AMOUNT DUE CHECKED <br /> DATE DATE REMITTE <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. PE ancVDate Mail Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />