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APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebbusiness in the jurisdictional area of the San J aquin Local Health District <br /> Business Name (DBA) McDonald c ,, is & Backhoe Address 4645 Hildreth Lane <br /> Owner T. R. McDonald Address Same <br /> " Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 931-0497 Emergency Telephone No. 957-402.7 <br /> 419 Contractor Licence No. 133679 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date !� <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> .. 1. 0 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 <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 Daterrime <br /> 4. ❑ SANITATION PERMIT <br /> Job—Address/Locatign <br /> Owner Advas <br /> _ SEPTIC TANK ❑ 6ESSP OL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHE <br /> S. ❑ 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 fA <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 applica ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an <br /> Jiees; <br /> JrryeWA reguuullaattiio s o th San Joaquin Loc/al Health District. <br /> APPLICANTS 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 /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> PEE <br /> Nee, C0 <br /> �4 <br /> LESS <br /> PRORATION <br /> im PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER Q <br /> Received by Date Receipt No. Permit No, lieudince Dalt I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAIELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 - <br />