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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign:The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> R <br /> LIQUID WASTE <br /> Application is herebymade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 07 Business Name (DBA) McDonad Septic Tank Service Address 464 Hildret an i <br /> z Owner T. R. McDonald Address Same <br /> z <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No931-0497 Emergency Telephone No. 57-4027 <br /> Contractor Licence No. 308171 I <br /> Applicants Name (Print)T• R. McDonald Title Date W <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> N3 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CRL. 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 s <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. •C <br /> Test Location Test Date/Time <br /> 4. El SANITATION PERMIT <br /> Job Address/Location— <br /> Owner Address -� <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ EW REPAIR OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 3R__ <br /> No. of Units Equipment Storage/Cleaning Location(s) 4 <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 /> 1 ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> r <br /> a 1 hereby certify that I have prepared this applicati and that the work will be done in accordance with San Joaquin County it <br /> ordinances, state laws, and rule d re lation o the San Joaquin Loc I Heal District. <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> I Fly.- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recaived by Date Receip[No. Permit No. Issuance Date Wailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2098 _ STOCKTON,CA 95201 <br /> 1 <br />