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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ti APPLICATION <br /> ,.. r (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> 4_ Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) McDonald Septic Tank Service Address <br /> aOwner T.R. McDOnald` Address Sams <br /> Firm Partners, Addresses and Telephone Numbers OQ <br /> CL <br /> Business Telephone No. 931-0497 Emergency Telephone No. 9579&027 �— <br /> Contractor Licence No. 30$171 <br /> L 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 /> i For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL, Liccnse Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> I 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 1' <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> weer ' Address <br /> SEPTIC TANK ❑ CESSP OL LEACHING FIELD 1:1SEEPAGE PIT L3PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY , EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 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/Amount/Mo. I <br /> t <br /> I hereby certify that l,.have prepared this application and tha he work will be done in'accordance with San Joaquin County <br /> ordinances, state laws, and r I sand ulati of the San a in Local Health D' rict. <br /> APPLICANT'S SIGNATURE _ <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 /> $ <br /> BASE EXPLANATION <br /> BILLING REMITTANCE REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> . ' <br /> AMOUNT <br /> FEE q-5 II d <br /> LESS <br /> PRORATION <br /> PLUS VIC <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt <br /> y No.. Permit No. Jissuande Dat Mailed Delivered �. . <br /> APPLICANT—RETURN ALL COPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICE 1601 E.HAZELTON AVE.,P.O.Box 2009S_TOCKTON,CA 95.201 } <br />