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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sur Sign The Application. <br /> , 4 r �_ <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) f <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> I Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildreth Lane <br /> a Owner. T. R. McDonald Address Stockton Ca 95212 <br /> I 2 Firm Partners, Addresses and Telephone Numbers <br /> r a Business Telephone No. 931-0497 <br /> Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 308171 <br /> dl <br /> Applicants Name (Print) T. . MCI)onald Title Owner -- ; <br /> Please check Applicable Category Date <br /> PUMPER VEHICLE . <br /> g ry (1-7)and Fill in the Required Information <br /> 1, ❑ PERMIT REGISTRATION (FOR EACH VEHICLE) s �, <br /> For July 1, June 30, 19 Disposa+,Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llc;,;-ise Renewal No. i. <br /> Capacity Gal., Weights &Measures No. t <br /> Equipment Parking Address J <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST 9,"yp <br /> .+ .. r • <br /> R.S. or R.C.E. Name R.S, or R.C.E. No. _ <br /> Test Location T%'t Date/Time <br /> 4. ❑ SANITATION PERMIT IV '. 1 " <br /> Job Address/Location all I f <br /> Owner .. Address <br /> 92 <br /> SEPTIC TANK TANK ❑ CESS OL `LEACHING FIELD ❑SEEPAGE PIT ❑ PACKAGE PL T <br /> PERMANENT ❑ TEMPORARY _k NEW ❑j REPAIR ❑ OTHER V74505. El CHEMICALTOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Ltocation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ° <br /> Operator Name <br /> Where Certified = pr I <br /> Plant.Location " � � Y . <br /> Plant Capacity � `�►°"~ No. Units-Served . __ - ate'~ <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. <br /> FF ; <br /> tr <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C "nty <br /> ordinances, state laws r and eguiatton he San Joaquin LocaHealth District. !" <br /> APPLICANT'S SIGNATURE X K <br /> 7 <br /> FOR DEPARTMENT E ONLY <br /> Fee Is Due:.❑ ANNUALLY ❑'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 J <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT i <br /> E <br /> DATE GATE REMITTED AMOUNTDUE E <br /> FEE ( µ T <br /> LESS l s <br /> PRORATION <br /> PLUS <br /> f I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt N. PermitNo� "!""� -19 <br /> —a, <br /> I r <br /> - APPLICANT—RETURN ALL arrceOat Mailed Delivered <br /> COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICE9 <br /> 1601 E.HAZELTN .O.Box 2009 STOCKTON,CA 95201 <br />