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Applications Will Be Processed When SuAPPLI ropeny N�,c•cM <br /> (For Non-Transterable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Address 4645 Hildreth Lane ,r <br /> Application is hereby made to carryon business in the jurisdictional area Of the San Joaquin Local Health District <br /> N Business Name (DBA) McDonald Se tic Tank Service same <br /> T . R. McDonald Address <br /> Owner <br /> Firm Partners, Addresses and Tele hone Numbers �7 4d2� <br /> 931-{ 497 Emergency Telephone No. <br /> aBusiness Telephone No. 308171 <br /> Contractor Licence No. Title Owner Date <br /> Applicants Name (Print) g` <br /> McDonald <br /> Please check Applicable Category (1-7)and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (DOPE A H VEHICLE) <br /> For July 1, June 30, 19 <br /> es <br /> Description(Make/Yr., Color) CAL. License No. CAL. Liccnse Renewal No. <br /> Serial No. <br /> Gal., Weights &Measures No. <br /> Capacity <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 R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location 00 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location A dress - <br /> Owner ❑ PACKAGE PLANT N <br /> SEPTIC T K CES OOL LEACHI IELD, SEEPAGE PIT 1:1 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY NEW <br /> ❑ EPAIR <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 1Disposal Situ <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Locations) `E <br /> July 1, -June 30, 19a Where Certified <br /> g, 13 PACKAGE TREATMENT PLANT For c <br /> Operator Name } <br /> Plant Location No' Units Served <br /> Plant Capacity } <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 , 7' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C1 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> �i <br /> be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and that the work will <br /> ordinances, state laws, an rul and egulati of the`an Joaquin Loc 1+1-lealth District, <br /> 12r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT ByJuly31 <br /> Fee I5 Due: ❑ ANNUALLY El PER REMITTANCE $ AMOUNT DUE CHECKED <br /> BILLING <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION Q <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit U. <br /> Issuance Date Mailed De4ivered <br /> Received by Date 1641 E.HAXELTON AVE.,P.D.Box 2049 570CK70N,G�9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES r� ` <br />