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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 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 /> y Business Name (DBA) McDonald Sutic Tank Service Address 4645 Hildreth 1,an <br /> a Owner T. R. McDonald Address Stockton Ca_95212 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 308171 <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. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O� <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. 0 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 p <br /> Job Address/ ocation & R'OLW <br /> OwnerAddress <br /> SEPTIC TANK CESSPOOL LEACHING FIELD 11SEEPAGE PIT 0 PACKAGE PLANT <br /> PERMANENT 0 TEMPORARY NEW 11REPAIR 1:1OTHER o� <br /> 5. C1 CHEMICALTOILETS. Fpr July 1, -June 30, 19 N <br /> Type Construction Disposal Site CD <br /> No. of Units Equipment Storage/Cleaning Location(s) o <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 /> t 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> [ SIZE: 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> L f <br /> i 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 rui nd regulatio the San Joaquin ,al Health District. fLk _0, <br /> oo' . <br /> APPLICANT'S SIGNATURE X <br /> Gf <br /> tciiii,50 . , <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.January 31 ❑ July"I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Qrl <br /> �a <br /> -1113M Z-� <br /> Received by Date Receipt No. Permit No I IssuarIce DtitpMailed Delivered <br /> t - _ <br /> -APPLICANT—RETURN ALL COPIES TO:-�„ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A .,P.O.Box 2009 STOCKTON,CA 85201. - <br /> i <br />