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Applications Will Be Processed When Submitted Properly Completed, Be sure 1 o sign t ne Appncanon. <br /> APPLICATION <br /> "I'loor Non-Transferable, Revocable,and SuspendaV11114 SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area Of the San Joaquin Local Health District <br /> L Business Name (DBA) McDonald Septic Tank S rVle ce _Address 464 Hildreth lana <br /> I. Owner T R McDonald "Address Sams <br /> < �I <br /> Firm Partners, Addresses and Telephone Numbers <br /> 14111.Business Telephone No. 931-0497 Emergency Telephone No. 957-4097 a Contractor Licence No. 308171 1 <br /> a Applicants Name (Print) T R McDonald Title Ownar Date In <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 /> r,Serial No. CAL. License No. CAL. Liccise Renewal No. <br /> Capacity Gal.,Weights& Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> Ihaa For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> LNo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> LTest Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Iner Add ss ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL yLEACHING I!� 11SEEPAGE PIT <br /> V-4PERMANENT 13TEMPORARY Jr,+ NEW 'Y� REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Ju`ne 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 --� <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/AmounVMo. <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 ul d regulations of I a an Joaquin Local H th District. <br /> r_APPLICANT'S SIGNATURE X � • � AfiD <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 $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> t. 414 <br /> FEE 41 45 r, <br /> LESS <br /> _ . PRORATION n <br /> h' <br /> PLUS {L <br /> PENALTY <br /> OTHER <br /> 1 <br /> ` OTHER <br /> Received by Date Receipt No. Permit No. I iss.arlice Data Metletl Dellveretl / <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520/>— <br /> .� -S?-moi-Grp O1 <br />