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Application Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. G <br /> APPLICATION i <br /> (For Non-Transferable;Revocable,and Suspendable) „ ^ s <br /> ENVIRONMENTAL HEALTH PERMIT (jyV SEPTAGE Q { <br /> LIQUID WASTE MW <br /> Application is herebl made to carry on business in the jurisdictional area of the San Joaquin Local Hea D'I� �1���n,� <br /> ilsiness Name (DBA) McDonald Septic Tank" v Address 4645 Ni 1 r`1 JJ 11 <br /> i Owner- _ T.. R.4 McDonald Address A`SITOP <br /> „Firm Partners,Addresses and Telephone Numbers <br /> a Business Telephone No. 931-0.497 Emergency Telephone No. 957-4027 <br /> 3 Contractor Licence No. 308171 <br /> L Applicants Name (Print) T RA'-McDonald Title owner Dale <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISIRATION,(FOR`EACH VEHICLE) - Q <br /> w ,.:. <br /> For July l'; :. 1 2- .to 30,'19 ' '�=�, - Disposal-41tes <br /> Description(Make/Yr.,Color)r"'_r A.. ' • t - r <br /> _ <br /> Serial No. =- CAL. License No. CAL. Liccnse Renewal No. <br /> = <br /> Capacity .II Gal.,Weights&Measures No. <br /> Equipment Parking Address 3 f <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30;.19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored 1 <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 i <br /> 0. ❑ SANITATION PERMITQ�LZ t ,I <br /> Job Address Location !/ { <br /> Owner Address ' <br /> �ySEPTIC TANK ❑ CE SOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ;yp PERMANENT ❑ TEMPORARYEW ❑ REPAIR ❑.OTHER - <br /> �[J CHEMICAL TOILETS For Juiy 1,-_Jun 30,.19 �!• , - "Dd <br /> pe Construction.. +y �` - - Disposal Site Q4 <br /> o.of Units •' - 4 Equipment Storage/Cleaning Location(s) °.- <br /> 6. ❑ PACKAGE.TR£ATMENT PLANT For July 1,-June 30, 19 > i Q.I <br /> Operator Named Where ertified I <br /> Plant Locations • - <br /> Plant Capacity - No. Units Served r 17I <br /> 7. ❑ LAUNDRY For July 1,-June 30;19 <br /> SIZE: ❑ Less Than 1,000 Sq.Ft�l,* ❑ More Than 1,000 Sp <br /> ❑ DRY CLEANING,Chemicals Use0/Amo6nt/MO. - lA`— <br /> ✓IU <br /> R. 4 <br /> �I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County. <br /> ordinances,state laws,and r les egulations of Joaquin Local Health Di 'ct. .JE <br /> APPLICANT'S SIGNATURE X r ( 1 <br /> - �IFOR DEPARTMENT USE ONLY <br /> Fee Is Due:L3 ANNUALLY. ❑ PE_R UNIT ER 417E It^ tb.{ACH [3 January 1 8 Received By January 31 ❑July 1 &Received 6y July 31 <br /> REMIT <br /> Eb t31LUNG REMITTANCE E <br /> 1 BASE EXPLANATI :.M_1 r�A�E DATE REMITTED AMOUNT DU6 AMOUNT <br /> ^' {/ <br /> LESS <br /> t U <br /> PRORATION <br /> PENALTY <br /> OTHER i l•`A''�a vS"'S 1 <br /> OTHER <br /> ..,... . .� . .. . f <br /> t <br /> �✓ 1 U� �I D8, a <br /> Receiv by Date Receipt No. Permit No. .Issuable Date Mi Del <br /> APPL NT—RETURN ALLCOPIES O: ENVIRONMENTAL HEALTH PERMR/SERVICES 1601 E.HA7:EL70N AVE.,P.O.am awe STO YON,CA <br />