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- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> OR Y •.,, :I. - APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTgGE O <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ' Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> k m Business Name IDEA) McDonald SeDtiC SETTT1Ce Address. 4645 H{ldrath Tane <br /> s Owner T. R. McDonald Address - yam <br /> v Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No..__931-0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 308171 ► <br /> ( L Applicants Name (Print) Title Orm EY - Date <br /> Please check Applicable Category(1-7)946 Fill in the Required Information <br /> IIIA 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19.1 (( Disposal Sites <br /> )_ Description(Make/Yr.,Color) - •'�f s - ___ i <br /> Serial No. Z`CAL. 0M,se NoM_ CAL.License Renewal No. <br /> Capacity Gal..Weights 8 Measures No. <br /> ( Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i For July 1, June 30, 19 <br /> No.of Vehicles Stored c <br /> W <br /> No.of Chemical Toilets Stored-7 _ <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. _ - w <br /> Test Location Test Dale/Time C <br /> 4. ❑ SANITATION PERMIT e l O O o Q <br /> -Job Address/Location /�,�a'� - j <br /> 0 ner a r= 'Yom aP.— Address G3 V ,2 G1 <br /> 9SEPTIC TANK ❑ CESSPSO,, T.I�LEACHING FIELD—❑'SEEPAGE'PIT—❑"PACK GE PLANT ' <br /> t [[]]``PERMANENT ❑ TEMPORAR6..a ❑ NEW REPAIR ❑ OTHER ` <br /> S. ❑ CHEMICAL TOILETS For July 1,r'June 30. 19 <br /> Type Construction Disposal Slte J.ak <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> t S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location t <br /> Plant Capacity No.Units Served AT% <br /> 7. 11 LAUNDRY For July 1,-June 30, 19 11 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLFAN`IN_G,--Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done.A accordance with San Joaquin County <br /> I ordinances, state laws,?andd'rules and regulattii�o he San Joaquin Local alth District. <br /> I APPLICANTS SIGNATURE `� r S - 66>`je6.•�. +�F <br /> E - FOR DEPARTMENT USE ONLY, <br /> Fee Is Due:'❑ ANNUALLY ' ❑ PER UNIT JK PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 &Recnved By July 31 <br /> tBILLING'- REMITTANCE f REMIT <br /> • BASE FJ`(PLANATION NTDUE DATE DATE REMITTED A,M�(OJV� AM CKE/D <br /> NT <br /> FEE . - ! w.. ­4 /i% ✓ <br /> LESS QY\•' . <br /> PRORATION (04 <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Y <br /> Received M - Oeta ;'_} Receipt N." , 1 Permit No. ci Issuance Date Mailed OsIN d <br /> - "APPLICANT-RETURN ALL COPIES TO. -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE;P.O.It.awe ET KION, A 95801 <br />