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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. �- <br /> APPLICATION <br /> 142rpj�o-2�/ (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 3 <br /> g_: . &44,c� LIQUID WASTE <br /> r. Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) CDonald Septic Tank Service". Address 4645 Hildreth Lane <br /> z Owner <br /> T . R•. McDonald Address Sarre ._._. <br /> e <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 931--0497 Emergency Telephone No. 957--4027 <br /> a Contractor Licence No. 308171 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date - <br /> Please check Applicable Category (1-7) and Fill in the.Required Information a <br /> 1. ❑ PUMPER VEHICLE-PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30 19 4 `'`Di'spasal Sees A \ NitN%. _ -' �r- <br /> r <br /> Description(Make/Yr., Color) <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 /> i <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ) ' <br /> I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location _ _ Test Date/ ime <br /> 4. 11 SANITATION PERMI � � <br /> Job Address/Location _ <br /> Owner r. r t ^ <br /> ❑ SEPTIC TANK CESS OC ❑ EACHING FIELD? -SEEPAGE PIT— ❑-&PAGKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑_OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT.,,,,,For July,1,=J.une 30,,19 <br /> Operator NameWhere Certified �t <br /> Plant Location ' -- �- <br /> ;�. i{ s t i .-No. Units Served t 1 ) <br /> Plant Capacity -.f4 w <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 6 ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I <br /> I hereby certify that I have prepared this applicati at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and I d r lations of h San aquin Local Health Vstric i <br /> APPLICANT'S SIGNATURE X <br /> Y <br /> 4 <br /> � wF.OR-DEPARTMENT,USE ONLY_._„ <br /> Fee Is Due: ❑.ANNUALLY+ ❑'`PER16NIT i�. PER SITE i3 EACH ❑ January 1 &Received By January 31 ❑.July 1 &Received By July 31 <br /> BILLING REMIT CE $ REMtT I <br /> t - BASE EXPLANATION + AMOUNT DUE CHECKED <br /> yDA,T, E_--REMITTED—..,,,.,�.,. �..--.�.... AMOUNT <br /> FEE <br /> LESS _ <br /> PRORATION <br /> G PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No.� Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALLCOP_IES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 "STOCKTON,.CA 95201 <br /> Or, <br />