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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> -M (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in thejurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) McDonal d Septi c Tank Servi ce Address 464 <br /> z Owner <br /> T. R. McDonald Address_ Same <br /> a <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-4 27 <br /> Contractor Licence No. 308171 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date <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 4 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic:,nse Renewal No. <br /> Capacity Gal., Weights &Measures No. 4 <br /> Equipment Parking Address -� <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 I ' <br /> No. of Vehicles Stored ) <br /> No. of Chemical Toilets Stored <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 <br /> 4. ❑ SANITATION PERMIT q.41 ' C <br /> Job Address ocation <br /> Owner it_ <br /> 9PERMANENT <br /> SEPTIC TA K ❑ CESSPOOL LEACHING FfELD SEEPAGEI�GE PL NT <br /> ❑ TEMPORARY NEW ❑ REPAI-R tOTRIER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ['!"* <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Gtleaning Location(§) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 -f+ <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/Amount/Mo. s� <br /> 1 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 rules and regulati of the San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> F� pp <br /> FOR DEPARTMENT USE6NLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ft <br /> PLUS <br /> PENALTY <br /> OTHER <br /> E <br /> OTHER <br /> Received by Date Receipt No. Permit No uance Date Mailed Deliv red <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.l3a■2009 STO KTON,C 95201 <br />