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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) <br /> ENVIRONMENTAL HEALTH PERMIT SPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on busines in the jurigdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) McDonald Septic Tan . Service Address 4645 Hildreth Lane, 95212 <br /> aOwner.._ T. Rl- Mrpona 1 d Address .1,a„me <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 91--0497 Emergency Telephone No. <br /> Contractor Licence No. 109171 <br /> �Applicants Name (Print)_ Title 0=e-r Date <br /> Please check Applicable Category(1-7) and Fill In the Required Information f <br /> +W r <br /> 1. 13 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. <br /> Equipment Parking Address [ n <br /> 2. ❑ PUMPER YARD 1 <br /> For July i, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time mo <br /> 4. ❑ SANITATION PERMIT T_ <br /> Job Address/LocationRF <br /> 5AddrO ner <br /> ess .� <br /> SEPTIC TANK ❑ CESSPOOL LI ACHING FIELDSEEPAGE PIT ❑ PACKAGE PLANT <br /> ,R PERMANENT 11TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 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. <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 Ind regulatio f the San Joaquin L al Health District. <br /> APPLICANT'S SIGNATURE X <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 /> EASE EXPLANATION DATE DATE REMITTED AMOUNTCIUE CHECKED <br /> AMOUNT <br /> �j <br /> FEE �= <br /> LESS <br /> PRORATION. <br /> PLUS " <br /> PENALTY <br /> OTHER <br /> VN <br /> OTHER TV Of 010 <br /> Received by Date Receipt No. Permit No. lssuancWDate I Wailed Delivered <br /> c APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bar 2009 STOCKTON,CA 95201 <br />