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Applications''Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPMAVON <br /> (For Non-Transferable;Revocable;and Suspendable) SEPTAGE <br /> I� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i� LIQUID WASTE' <br /> Application is hereby made to carry on business in the jurisdictional area of the San,Joaquin Local.Health District, <br /> FBusiness Name (DBA) McDonald Septic & B ckhoe Address _. 6 _`Hildreth Lane <br /> i Owner. T. ;R... McDonald Address. <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> a Business:Telephone No. Tell14 Emergency Telephone No. . .7 02� <br /> _J Contractor Licence No. J-., .6 7-9. <br /> Applicants Name (Print) �' • IIP . .MC1]Oriald Title Wrier Date <br /> .,.. <br /> Please check Applicable�Category.(1-7) and Fillort,the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT,REGISTRATION-(FOR EACH VEHICLE)} <br /> 1Os1 � t <br /> For July-1, _ - June 30, 19N�'� - .. Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, LicensefNo. CAL. License Renewal No. <br /> Capacity �� Gal.,Weights& Measures No. <br /> Equipment Parking Address <br /> 2. 11 PUMPER YARD i r,— '` <br /> OP <br /> For July 1, June 30, 19 ,' - 'low <br /> i r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored IIiI <br /> 3. ❑ PERCOLATION TEST Il i #_V I <br /> R.S. or R.C.E. Name II fl 5. or R.C.E.No. <br /> Test Location IM Tes.Da /Time <br /> 4. ❑ SANITATION PERMIT IM <br /> Job Address/ catiory <br /> Owner Address �'• <br /> 13 SEPTIC TANK 1iCESSP06L ❑ LEACHING I=,IELD El SEEPAGE ❑ PACKAGE PLANTt A <br /> 11PERMANENT ❑ TEMPORFARY ❑ NEW RREPAIR ❑ OTHER �} <br /> S. 1:1 CHEMICALTOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units I� Equipment Storage/Cleaning Location(s) 4 ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name ) Where Certified <br /> Plant Location <br /> Plant Capacity i� (� No. Units Served <br /> 7. 11 LAUNDRY For July -1;-June 30, 19 —* — <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ M6re Than 1,000 Sq.,Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ILL-, <br /> 4i • t <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,F d r es and re tions of the San J quin Local Health District. <br /> I ,_ <br /> APPLICANT'S SIGNATURE X <br /> IAiI- FOR DEPARTMENT USE•ONLY <br /> Fee WDue: ❑ ANNUALLY ;!L ❑ PER UNIT- ❑ PER SITE i ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> .... .`. { __.... REMIT <br /> BASE�IEXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> !! DATE DATE 'REMITTED AMOUNT <br /> FEE ,19, <br /> f LESS Y/ <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> r pp <br /> OTHER <br /> Received 6y Date' Receipt No Permit No. ssuance'Date Maiied Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `1601 E.HAZEL70N AVE.,P.O.Box 2009 STOCKTDN,-CA 85201- <br /> I� 7 �i <br />