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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,y0 (For Non-Transferable,•Revocable,and Suspendable) <br /> 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 = F <br /> Business Name (DBA) McDonald Septic Tank Service _ Address 6_45 Hildreth Lane <br /> a Owner T 3 MCD nald Address Stpsk 0 212 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 1 <br /> a Business Telephone No._.- 93 —0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. <br /> -308171 <br /> Applicants Name (Print) Title Ownar Date <br /> Please check Applicable Category (1-7) and Fill in the Required information <br /> 1. ❑ 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 /> r 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 /> 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 <br /> 4. ❑ SANITATION PERMIT -1 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TA'Nr CE5 OOL ❑ LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY .X' ❑ NEW ❑ RE=PAIR ❑ 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 s For July 1, -June 30, 19 -� <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served 1 <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`th-e-work-will..be done in accordance with San Joaquin County <br /> ordinances;state laws, and rules d r gulations a San Joaquin ocal alth District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY 4� <br /> Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3)-_ ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 31 DATE DATE REMITTED AMOUNT <br /> FEE u ��. Lq <br /> - <br /> i <br /> ...,,.LESS <br /> PRORATION # <br /> PLUS Z4 �f F p/ <br /> PENALTY /AfK �7—p/ t Y <br /> OTHER r <br /> OTHER <br /> ,. Received by Date Receipt No. Permit No. Issuance Date Mailed —�Delivered I <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.B"�2009 STOCKTON, A 45201 <br /> -U r 5 c—FP/bV. <br />