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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ~ <br /> APPLICATION <br /> la- :. (For Non-Transferable, Revocable, and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> iL1QUlr WASTE <br /> Application is hereby'made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) MC DONALD SEPTIC TANK SERVICE Address <br /> 4645 HILDRETH LANE <br /> i Owner MC DONALD] Address <br /> a - I <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 7-4027 <br /> IL Business Telephone No. 931-0497 Emergency Telephone No. <br /> Contractor Licence No. 30 171 <br /> Applicants Name (Print) 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 Disposal Sites. <br /> Description(Make/Yr., Color) ill <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> r 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 �j <br /> Job Address/Locationv _-A <br /> A t7_71111111111 in IV <br /> Owner � Address <br /> SEPTIC TANK ElESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> i PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Ju a 30, <br /> t 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. <br /> k <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 rules a regulatis of the San iioaqy4n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> t tFORD' i?'4 <br /> t EPARTMENT USE ONLY <br /> Fee is Due: El ANNUAL '4 ❑,PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31' ❑ July 1 &Received By July 31 <br /> '..._�.- REMIT <br /> BILLING REMITTANCE- 1f 4$ R AMOUNT DUE v; CHECKED <br /> I BASE —EXPLANATION- - - -� <br /> i -DATE �� DATE�„rlJ REMITTEDtr� ". AMOUNT ,s <br /> FEE YF 9 r- <br /> 3 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY N# <br /> OTHER <br /> } <br /> OTHER <br /> Received by 1-1)i Date Receipt No. - Permit No. - Issuance Date. Mailed etivere <br /> APPLICANT—RETURN ALL COPIES TO:.: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE.,P.Or 2009 STOCKTON,CA 95201 <br /> -1 FA 0'ffx�yei I ,SC nc�y Sc l m <br />