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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _ <br /> r (For Non-Transferable, Revocable,and Suspendable) may- 3 <br /> SE PTAGE-', <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 ` <br /> Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildreth Lane ' ` <br /> * <br /> ockton Ca 95212 a Owner T_ lt_ MrI)n•nald -Address - <br /> Firm Partners, Addresses and Telephone Numbers r <br /> CLIw Emergency Telephone No._ 957-4027 �— <br /> a Business Telephone No. 9enc Y P <br /> ,, <br /> Contractor Licence No. o <br /> LApplicants Name (Print) - Mrl)anal Title Owner Date ' <br /> Please check Applicable Category[(1-7}and Fill in the Required Information -J <br /> 1. 11 PUMPER VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE) ;' -J <br /> For July 1, June 30. 19 HA. Disposal Sites <br /> Description(Make/Yr., Color) - <br /> jSerial No. �`' ` *CAL. License No. "'-CAALI=—,se,Renewal No. �fi <br /> Capacity Gal., Weigh & Measures No. <br /> Equipment Parking Address " <br /> 2. ❑ PUMPER YARD �� ^ <br /> For July 1, June 30, 11911— <br /> No. <br /> 0, 191 No. of Vehicles Stored 1 t 1 <br /> I: No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location IIS Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addres ocatio # * <br /> Owner <br /> cc�yyy��l - ~❑ <br /> � Address � ' <br /> SEPTIC TANK '11' ESSPOIOL F LEACHING FIELD SEEPAGE SPIT„ PACKAGE PLANT 1 <br /> I PERMANENT -0 TEMPORARY NEW , REPAiR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July i, -June 30, 1 i x ' <br /> Type Construction ��' Disposal Sitte <br /> No. of Units Equipment Storage/Cleaning Location(s) R <br /> t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,;19 {f <br /> Operator_Name <br /> f I�: Where Certified i <br /> Plant Location d <br /> Plant Capacity �6 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Ton 1,000 Sq.'kt., ❑ More Than 1,000 Sq.±Ft. <br /> ❑ DRY CLEANING;Chemicals Used/Amount/Mo. ` <br /> f <br /> y ' Y <br /> I <br /> I hereby certify that IIhave prepared this applicat' and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,;Ian r n la 'on f e San Joaquin Loc 1 Health District. { <br /> APPLICANT'S SIGNATURE X <br /> r t <br /> 7� <br /> l 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 <br /> REMIT <br /> BASE. EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS !M <br /> I PRORATION Il`i <br /> PLUS <br /> PENALTY-] <br /> OTHER ■ �I�I �� <br /> OTHER <br /> Ly <br /> Received by _%; Date Receipt No. Permit No - i*u!�ncA Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O•ao■2409 . STOCKTON_,.CA 95201 - <br />