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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,%/br Non-Transferable, Revocable, and Suspendal., <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 <br /> Business Name(DBA) McDonald Septit! Tanis S ViAddress 4645 TTi ldrath Lane <br /> Owner T. R. McDonald Address 4645 HildEeth T anP <br /> Firm Partners, Addresses and Telephone Numbers <br /> iBusiness Telephone No. 931-0497 Emergency Telephone No. 4,57-4097 <br /> Contractor Licence No. 308171 <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. ❑ 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 A <br /> For July 1, June 30, 19 l <br /> No. of Vehicles Stored <br /> a•. <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ C <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 L <br /> Job Address/Location 74AI 77 [[C/ <br /> Owner Address <br /> SEPTIC TANK P CESSPOOL LEAC NG FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 11 TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 a(�I <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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regullitions of topan Joaquin Local ealth strict. <br /> 11 <br /> APPLICANT'S SIGNATURE X / <br /> e� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT %PER SITE ❑ EACH ❑ January t 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED It AMOUNT DUE CHECKED <br /> 1. /` AMOUNT/ <br /> FEE es yf C/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7Of <br /> Received by Date Receipt No Per it No. Issuance Date Mailed ;5TO <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.0.2009 TON,CA 95201 <br /> Lf"s . i_ //— -1 /mss ._ � Oy <br />