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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) x <br /> - - � ENVIRONMENTAL HEALTH PERMIT <br /> ` SEPTAGE <br /> LIQUID WASTE II <br /> Application is hereby made to carry on busiress in the jurisdictional area of the San Joaquin Local Health District a <br /> y Business Name (DBA)—McDonald Septic Tank Service Address 4645 Hi l drpi 1t lana <br /> a Owner T- R_ MCDOnald Address Samp <br /> J Firm Partners, Addresses and Telephone Numbers CO <br /> a. Business Telephone No. 931-0497 Emergency Telephone No.. 957-4027 U, <br /> Contractor Licence No. 308171 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date i3T <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE), t <br /> For July 1, June 30, 19 -W ' , Disposal Sites` F <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address 4 <br /> 2. ❑ PUMPER YARD 4 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ..y 1 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name s R.S. or R.C.E. No. r� <br /> Test Location y - - '- Test Date/Time ; <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner } Address • t <br /> ❑ SEPTIC TANK ESSPiS_LL 11 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> .. - . <br /> [] PERMANENT ❑ TEMPORARY ❑ NEW °REPAIR C1 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 "r F <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 <br /> Operator Name ` `i Where Certified <br /> Plant Location . t - <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. <br /> ❑ 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 <br /> ordinances, state laws, and rules and re ulations an Joaquin Local He54h District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4 4S � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> } <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit- o. Istuancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -- - 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,,CAd95201 <br />