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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) SEPTAGE S <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 /> ,F Business Name (DBA) McDonald Septic Tank Service Address ._ <br /> � 464-5 Thi 1 drol, T.t .ane <br /> z Owner `1 . R. McDonald Address same <br /> Q <br /> Firm Partners, Addresses and Telephone Numbers <br /> AL Business Telephone No. 931-4497 Emergency Telephone No. 957-4027 <br /> -J Contractor Licence No. 308171 <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. t <br /> Equipment Parking Address f <br /> 2. ❑ PUMPER-YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored N <br /> No. of Chemical-Toilets Stored W <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.'Name R.S. or R.C.E. No. C d <br /> Test Location Test Date/Time G <br /> 4. ❑ SANITATION PERMIT (� i A_ <br /> Job Address%Location r <br /> Owner Address <br /> SEPTIC TAN , ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 5 <br /> PERMANENT ❑ TEMPORARY NEW rVREPAIR �❑ OTHER �! <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 3 r <br /> Type Construction <br /> Disposal Site a %' <br /> t <br /> No. of Units Equipment Storage/Cleaning Location(s) t <br /> S. ❑ 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. F••, - t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. " { <br /> T x I <br /> 4 <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 rul s a d re ns of the San Joquin LOcal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR'DEPARTMENT USE ONLY <br /> ` I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 01 PER SITE ❑ EACH []'January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ` I <br /> PRORATION <br /> PLUS ` <br /> PENALTY j <br /> I <br /> OTHER <br /> OTHER <br /> r <br /> Received by Date Receipt No. Permit No. Issuance Date - Mailed Deliv ed <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA7ELTON AVE.,P.O.Boa 2009 -STO K 1 <br /> - s <br />