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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign•The Application. <br /> 9 APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) SEPTAGE <br /> t�. f 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 /> rn Business Name (DBA) McD6nald Septic Tank Service Address 4fi45Hi 1 J'Pth 1 anP <br /> a Owner T. R. McDonald Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 93P"-0497 Emergency Telephone No. 9�r7 11��7 <br /> Contractor Licence No. 308171 <br /> Applicants Name (Print) <br /> T. R. McDonald Title Owner Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information r- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s ; > <br /> For July 1, June 30, 19 `� Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. ii I CAL. License No. CAL.. License Renewal No. , <br /> Capacity 1l Gaal., Weights &Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 I ' �--^---� --- <br /> No. of Vehicles Stored ' I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> R.S. or R.C.E. Name. R.S. or R.C.E. No. <br /> I ( Test Date/Time I <br /> Test Location , <br /> 4. ❑ SANITATION PERMIT <br /> Job Addre /Lacatto <br /> Owner <br /> 1 rAddress f► ---� ��-} �-► I <br /> - <br /> ❑ SEPTIC TANK ❑ CESSP,OOL ❑ LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT C3TEMPORARY: ❑ NEW <REPAIR ❑ OTHER S C' <br /> .� I <br /> 5. E] CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site € <br /> I Equipment Stora Storage/Cleaning Location(s) ) �1 <br /> No. of Unitsg } <br /> 6. ❑ PACKAGE TREATMENTIPLANT For July 1, -June 30-19 <br /> I r <br /> Operator Name WhbFe Certified _ r <br /> �; j <br /> Plant Location I <br /> Served <br /> Units N <br /> Plant Capacity o. ns <br /> t <br /> 7. ❑ LAUNDRY For July 1, -IJune 30, 19 } <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I <br /> ❑ DRY CLEANING, Chemicals�U sed/Amount/Mo. _ <br /> f <br /> I hereby certify thatlf•have prepared this application and that the work will be done in accordance,wlth.San Joaquin County <br /> 'sand an Joa <br /> legulations of <br /> ordinances, state laws, and rulequin Local Health District. <br /> I <br /> i <br /> E APPLICANT'S SIGNATURE X TI <br /> € I <br /> .__ 4— <br /> i _ <br /> } FOR DEPARTMENT USE ONLY <br /> w <br /> Fee Is Due: El ANNUALLY; ❑ PER UNIT ( ❑ PER SITE ❑ EACH ❑.January 1 &Received By January 31 ❑July 1 &ReceiveRdEMIIBy Tuly 31 <br /> BILLING RE TTANCE ti $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE TE REMITTED � � AMOUNT <br /> FEE <br /> LESS 1 <br /> PRORATION s '� <br /> f / <br /> PWS <br /> PENALTSY_ <br /> ^ OTHER * <br /> OTHER <br /> '36 t <br /> Received by Date s. Receipt No. 4 Permit No. Issua ce Date Mailed l7elivered r.V Zf <br /> X <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAXELTON AVE.,AYE. P.O.Box 20u9 STOCNTO 52F71 <br /> l C72— <br /> Fi <br />