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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 /> i y Business Name (DBA) McDonald 'Septic Tank ServiceAddress 4645 Hildreth Lane <br /> a Owner T. R. McDonald Address- <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 931-0497. 957-4027 <br /> a Emergency Telephone No, <br /> Contractor Licence No. <br /> L Applicants Name (Print) T. R• McDonald Title 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 1 Disposal Sites a <br /> Description(Make/Yr., Color) <br /> } <br /> Serial No. CAL. License No. CRL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures No. ,La i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 34, 19 <br /> No. of Vehicles Stored - 1 <br /> No. of Chemical Toilets Stored .r <br /> 3. ❑ PERCOLATION TEST r <br /> R.S, or R.C.E. Name R.S. or R.C.E. No <br /> Test Location Test Date/Time -= <br /> 4. 11 SANITATION PERMIT f ` k <br /> Job Address/Location 4 <br /> Owner Addres <br /> ❑ SEPTIC 4 ANK CESSPOOL ❑.LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 'REPAIR ❑ OTHER <br /> S. ❑ 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 P <br /> Operator Name TWhere Certified _ <br /> Plant Location i + <br /> Plant Capacity ( No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f ; <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑More Than 1,040 Sq. Ft. a ~ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo <br /> y <br /> I hereby certify that I have prepared this application that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a ' reg ti s f t \5a Joaquin Locaict. <br /> APPLICANT'S SIGNATUREX <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE 11 EACH El January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE - CHECKED <br /> AMOUNT <br /> FEE Vt � <br /> { <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY It <br /> OTHER ` <br /> f <br /> OTHER <br /> Received by DateReceipt No Permit No I suance Date Mailed Delivered <br /> APPLICANT—RETURN,ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />