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APPLICATION <br /> Von-Transferable,Revocable,and Suspendable) <br /> L 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 /> Lsiness Name(DBA) IICDonald Septic Tank Service Address 4645 Fi ldrpf-tn T.anp <br /> Owner T. R. McDonald Address 4645 Hi 1 ripth T.anp <br /> m Partners.Addresses and Telephone Numbers. <br /> Isiness Telephone No. 9.31-0497 Emergency Telephone No. 95,7-4097 <br /> ontractor Licence No. 308171 <br /> Applicants Name (Print) T E Mr-171Ona I _ Title O=pr Date <br /> Iease check Applicable Category (1-7) and Fill in the Required Information <br /> L ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 _ Disposal Sites <br /> �scription(MakefYr.,Color)—.- _ <br /> a rial No. CAL.License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Fquipment Parking Address <br /> ❑ PUMPER YARD <br /> r July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> D <br /> . of Chemical Toilets Stored 1C <br /> ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> -est Location Test Date/Time <br /> ❑ SANITATION PERMIT <br /> G <br /> 4ob Address/Location 77 <br /> Owner Address <br /> Z'SEPTIC TANK R CESSPOOL VE NG FIELD .SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ REPAIR ❑ OTHER <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 <br /> f "ype Construction Disposal Site <br /> `lo. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> dlant Location } <br /> ant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> ;IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> L] DRY CLEANING,Chemicals Used/Amounl/Mo. <br /> LI 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 regulations oft n Joaquin Local Health strict. <br /> LaPPLICANTS SIGNATURE X 1 t 6 <br /> r ' <br /> ` �( FOR DEPARTMENT USE ONLY <br /> rF <br /> e: ❑ ANNUALLY ❑ PER UNIT APER SITE ❑ EACH ❑ January 1 d Received BY January 31 ❑.July 1 S Receive0 By July 31 <br /> REMIT <br /> LBASE IXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> �1 DATE DATE REMITTED / AMOUNT <br /> �/� <br /> LN <br /> LLby Date fleceipt No. Per1NoeO DelivANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STO TON,CA 95201 <br />