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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sig The Application. <br /> APPLICATION <br /> �'- ) t. (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District _1� <br /> y Business Name (DBA) McDonaldSan i c- Sar#i t-p Address 4645 Hi1drth Lane <br /> i Owner <br /> T, R. McDonald Address Same <br /> C <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 9310497 Emergency Telephone No. 957-0427 <br /> Contractor Licence No. 303171 <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 <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License 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 <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST �..J <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Nest Date/Time <br /> 4. 11 SANITATION PERMIT � � p� t� L1_ L�'��ffrrJ'1 <br /> Job Address/Location 1� <br /> Owner - Address <br /> a <br /> SEPTIC TANK Jff CESSPOOL LEACHING FIELD f`SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW d REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <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 /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <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, and rules and regulations of tl=San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X lof ' <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE ATE REMITTED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R ce, d by ate Receipt No. Permit No. U l D Issuance Date Mailed Delivered <br /> APPLICANT—RETURNALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 9520 <br />