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letea <br /> __ -- <br /> Applications Will Be Processed When SubAPPp <br /> L�Cp1TION <br /> For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ,. <br /> ENVIRONMENTAL HEALTH PERMIT a <br /> LIQUID WASTE <br /> v <br /> 4645 Hildreth mane j <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA} McDonald Se tic Tank Service Address Stockton, Ca 95212 <br /> aOwner T. R. McDonald Address <br /> S6) Firm . <br /> Partners, Addresses and Telephone Numbers Telephone No957-4027 <br /> 931-0497 Emergency p <br /> aBusiness Telephone No. 308171 <br /> _J Contractor Licence No. Title owner (Date <br /> Applicants Name (Print) T. R. McDonald <br /> Please check Applicable Category.(1-7) and Fill in the Required Information �} <br /> i, ❑ PUMPER VEHICLE PERMIT REGISTRATION-(F <br /> yt,kACH VEHICLE) t <br /> Disposal Sitesi <br /> For July 1, June 30, 19 J f + <br /> Description(Make/Yr., Color) + CAL. Licc-,Ise Renewal No. <br /> + CAL. License No <br /> Serial No. <br /> Capacity Gal.,Weights &Measure% No. <br /> k Equipment Parking Address <br /> f 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 <br /> 4 f <br /> No. of Vehicles Stored , <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TESTR.S. or R.C.E.No. <br /> R.S. or R.C.E. Name ) Test Date/Time _ <br /> --------------- <br /> .: <br /> r Test Location -------- <br /> q, I <br /> ❑ SANITATION PERMIT `. <br /> Job Address/,L ation Address <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK` ❑ CES TOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br /> ❑ TEMPORARY ❑ NEW 1:1 REPAIR ❑ OTHER <br /> 11 PERMANENT <br /> y. 131,_June 30, 19 CHEMICAL TOILETS For July d. <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 6. IJPACKAGE TREATMENT PLANT For July i, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity { <br /> 7, 13 LAUNDRY For July 1, -June 30,�9More'kTh n 1 000 Sq. Ft. <br /> SIZE: C2 Less Than 1,000 Sq. Ft., y' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 application and that the work will be done in accordance with San Joaquin County <br /> I I hereby certify that l have prepared this aq <br /> - r an regul Uns of the San aquin Local Health District. <br /> ordinances, state laws, and <br /> APPLICANT'S SIGNATURE X f r <br /> FOR DEPARTMENT USE ONLY <br /> y Jul i &Received.ey July 31 <br /> l ❑ PER SITE ,f,.❑ EACH ,❑ January i &Received 8y January 3i_ ❑ y REMIT <br /> Fee Is.Due: ❑ -ANNUALLY ❑ PER UNIT CHECKED <br /> ' REMITTANCE+ s $ AMOUNT DUE <br /> i1 gILL'ING _ REMITTED AMOUNT <br /> f } BASE EXPLANATION DATE DATE _ <br /> f 1 0 <br /> •.{F = F Q ,� �. <br /> k FEE - lY <br /> tJ <br /> i LESS r T k� �•� /"� <br /> PRORATION s M y w <br /> PLUS <br /> —PENALTY <br /> - OTHER95 <br /> f <br /> OTHER166 <br /> i ance ate Mailed Delivered <br /> -Receipt No. Permit No. <br /> I <br /> ei d by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT�RETURN ALL COPIES - <br />