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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Tne ApptR:atton. <br /> APPLICATION <br /> �- (For Non-Transferable,Revocable;and Suspendable) SEPTAGE ~ <br /> ENVIRONMENTAL HEARTH PERMIT k <br /> LIQUID WASTE <br /> Application is herebymade to carry on business in the jurisdictional area of the Sand aquin Local Health District <br /> Business Name (DBA) McDonald- Se tic & Backhoe . - Address . . 4g 45 Hil'dre.th Lane <br /> a Owner �1 R. .McDonald Address Same <br /> Y Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _ l-� 7, y -Emergency Telephone NO-.--917-402 "A <br /> Contractor Licence No. ...1336791 - <br /> T. R... McDonald Title• owner Date f <br /> L Applicants Name(Print) . <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 _ l� <br /> Description(MakelYr.,Color) <br /> CAL.License Renewal No. <br /> Serial No. . CAL.License No. . <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking.Address <br /> -- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30; 19 w <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored �. <br /> 3. ❑ PERCOLATION TEST . <br /> .R.S.or R.C_E.No. <br /> R.S.or R.C,E.Name <br /> Test Date <br /> 4. <br /> � <br /> Test Location �, - r. �- <br /> •4. ❑ SANITATION PERMIT ✓r; 1 <br /> Job-Address/Location r <br /> Owner d s' pl <br /> 2 SEPTIC TANK ❑ ESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ TEMPORARY NEW- J REPAIR 13 OTHE <br /> PERMANENT <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June.'30, 19 <br /> Type Construction 6 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) - <br /> e. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location l <br /> Plant Capacity No.Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19- <br /> SIZE': <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., �❑ More Than 1,000 Sq.Ft. <br /> 0 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> f <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 les regulatio s o th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE r <br /> SIC <br /> FOR DEPARTMENT USE ONLY <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 5 S Received By January 31. ❑Joy 1&Received <br /> Ely `y,31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - OATEN DATE REMITTED AMOUNT <br /> FEE 14 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> lssunce Da Mailed Delivered <br /> Received by Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O,Boy 2009 STOCKTON.CA 95201 <br />