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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> � <br /> f �!O (For Non-Transferable, Revocable, and Suspendable) -- SEPTAGE <br /> `4 ! ENVIRONMENTAL HEALTHIPERMIT <br /> LIQUID WASTE <br /> F <br /> Application is hereby made to carry on business in the 1'urisdictional-area of_the San'oa uin Loja`Healt District <br /> Business Name (DBA)_ McDonald Septic & Ba hoe ' -Address :�.64+ H1 Cir'eth Lane <br /> z Owner :, _ w, _.., 'T•. R. McDonald ,,.. ..Address. ---Same . ,. <br /> J Firm Partners, Addresses and Telephone 1 Numbers <br /> IL <br /> Business;Tefephone No. L �l��� - _ Emergency 79 57 <br /> eiephone_No <br /> 6'7 9.. <br /> Contractor Licence No. �. ; <br /> Applicants Name (Print) T. R­-Mc .Donald.. Title, 0W21eY' Date ~ <br /> Please check Applicable Category (1-7)an&Fill in the Required Information r :", <br /> 1, ElPUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) Can <br /> 4. k . <br /> For July 1, June 30;19 Disposal Site"s - - - -=- <br /> Description(Make/Yr., Color) <br /> Serial No. fi CAL .License No. CAL. License Renewal No. 3 <br /> l.- - r4; <br /> Capacity Gal., Weights &.Measures No. <br /> Equipment Parking Address ) '� <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,'19 K <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. C1PERCOLATION TEST N"' 1 {# <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/Locatipn o ? 6 _ <br /> Owner Address <br /> ❑ SEPTIC TANK CES POOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT: <br /> ❑ PERMANENT 0 TEMPORARY : ❑ NEW ❑ REPAIR ❑ OTHER 3 c ` <br /> 5. ❑ CHEMICAL TOILETS For July, 1,-June 30, 19 _ 4- <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 16. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 .. y <br /> Operator,Name Where Certified <br /> `Plant Ldcatio(1 <br /> Plant Capacity No. Units Served <br /> 1.-C1 LAUNDRY, For'July 1, -June 30, 19 <br /> :SIZE, .-`:❑ L'e'ss 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 application and that the work will be dorie in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati of the San Joaqui ocal Health District. <br /> -APPLICANT'S SIGNATUREX <br /> 91 L <br /> -y, <br /> -FOR-DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY '' 4:3'PERUNIT''--. ElPER SITE j= ❑ EACH ❑iJanuaryl &Received By January 31 July.1 &Received By July 31 <br /> REMIT <br /> —BILLING -REMITTANCE $ t <br /> BASE EXPLANATION 4 �' +�- _ 'iAMOUNT DUE - .CHECKED <br /> - - DATE - `DATE REMITTED Q AMOUNT <br /> .. e h., r -'e1J •',R .A y - mss. _.;}'..n -'+� �j <br /> • FEE .. , <br /> ~i <br /> LESS <br /> PRORATION <br /> PLUS . J •� *, <br /> PENALTY /N / 3 [i V <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL,HEALTH PERMITISERVICES 1601 E.HAZELTON AMTS.,P.O.Bo■2009 STOCKTON,CA 95201 <br /> a ' <br />