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Applications Will Se Processed When Submitted Properly Completed. tae Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> r " s 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 /> O Business Name (DBA) MC DONALD SEPTIC TANK SER C <br /> q Owner T. R. MC DONALD Address Address <br /> SAME <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a.IL Business Telephone No. 931-047 Emergency Telephone No.Q57—Ltd <br /> _. <br /> Contractor Licence No. 308171 <br />` L Applicants Name (Print) T. R. Title Date <br /> If Please check_Applicable Category (1-7)and Fill in the Required Information _ <br /> 4. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) # <br /> rFor July 1, June 30, 19 Disposal Sites <br /> Description (Make/Yr., Color) <br /> r. 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 /> .Na. of Chemical Toilets Stored i <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Tim <br /> 11SANfTAT10N PERMIT <br /> J <br /> _ ob Address/L ation <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> `PERMANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J no 30, 19 <br /> F Type Construction Disposal Site _ <br /> {No. of Units Equipment Storage/Cleaning Location(s) <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 /> 7. 11LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ElLess Than 1,000 Sq. Ft., 11More Than 1,000 Sq. Ft. <br /> El DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County n <br /> ordinances, state laws, and r les aadregulationsSan Joaquin Lo al He District. <br /> APPLICANT'S SIGNATURE X n07 <br /> 1 - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 ived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT { <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE ��. REMITTED <br /> AMOUNT <br /> FEE � y 5 � �S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER } ] I <br /> W OTHER <br /> Received by Date Receipt No. Permit No. <br /> Mailed Delivered <br /> Iss ante ate <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON,CA 95201 - <br /> I /'4 1/1-4-A —r — li�,1 <br />