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( ApplicationsWill 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 /> k LIQUID WASTE <br /> f Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> [ F Business Name (DBA) McDonald Se tic Tank Service Address 4645 Hildreth Lane <br /> a owner T. R. McDonald Address Stockton Ca 95212 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _9__ 1-04 .I.� <br /> Emergency Telephone No. 957-4027 <br /> 1 <br /> Contractor Licence No. 3081,71 <br /> _ <br /> Applicants Name (Print) T. R. McDonald <br /> E Title OWIl-er- Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> t. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE), <br /> For July 1, June 30, 19 ^y <br /> Disposal5ites) } <br /> Description(Make/Yr., Calor) - <br /> Serial No. CAL. License No. CAL. Liccrise 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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name- , r, R.S. or R.C.E. No. <br /> Test Location , ' <br /> Test Date/Time - 3 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> 17 SEPTI ANK ❑ CESSPO L `' ' <br /> EACHING FsIELDti ❑.SEEPAGE PIT t Lt PACKAGE,PLANT <br /> tt-PERMANENT 11 TEMPORARY _. NEW REPAIR _+ J.—.. <br /> . ❑ OTHER" F� <br /> P` ..(- <br /> 5. ❑ <br /> CHEMICAL TOILETS For July 1, -Ju 30, 19 Q ' <br /> Type Construction ; <br /> Disposal Site <br /> No. of UnitsEquipment Storage/Cleaning Location(s) # f 1 <br /> ti. 11 PACKAGE TREATMENT PLANT For July 1, -Jeune 30, 19 f l JJ <br /> Operator Name _� t Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served 'A <br /> 7. ❑. LAUNDRY ,For July,j, -June 30, 19SI iEa = ti F <br /> f Less Than 1,000 S!, Ft., ❑'More Than 1,000 Sq. <br /> Ft.33r t <br /> El DRY CLEANING, Chemicals Used/Amount/Mo. A ii <br /> i <br /> t � <br /> I hereby certify that I have prepared this application atha th ark will be done in acc dance.with 5antaquin County <br /> ordinances, state laws, a re ulati a San aquin Local Health District. <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 /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER A r # <br /> Received by Date Receipt No. <br /> P Permit No - Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, ,y;. _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1 <br /> _ <br />