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4 <br /> A plicatlons-Will Be Processed When Submitted Properly Completed. BeSureTO SignTneApplication. , <br /> APPLICATION <br /> t+ jy <br /> $ i (For Non-Transferable, Revocable, and Suspendable) <br /> *` ( ENVIRONMENTAL HEALTH PERMIT SPPIAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) MC DONALD SEPTIC TANK SERVICE Address 4645 HILDRETH LANH <br /> z Owner T. R. MC DONALD' Address SAME :t. <br /> a <br /> u Firm'Partners, Addresses and Telephone Numbers 957-4027 <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. <br /> Contractor Licence No, . t 308171 i <br /> Applicants Name (Print) T. R. MC .DONALD Title OWNER Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> k 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal-Sites <br /> Description(Make/Yr., Color) _ <br /> SCAL. LicC tse Renewal No. <br /> Serial No. CAL. License 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 /> I R.S. or R.C.E. Name_ <br /> R.S. or R.C.E. No. <br /> Test Location est Date/Time <br /> 4. ❑ SANITATION PERMIT tY� <br /> Job Address/Local n D <br /> I IrrOiiiiyy������wner Address <br /> ❑ PACKAGE PLANT <br />( SEPTIC TANK CESSPOOL L1:1EACHING FIELD SEEPAGE PIT <br /> f <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 1:1 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> I Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Loc <br /> ation{s) <br /> . 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> i Operator Name <br /> S Plant Location <br /> Plant Capacity No. Units Served <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> t ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wltVan Joaquin County <br /> ordinances, state laws, and rules d r ulatio a San Joaquin Local H lth District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ~ <br /> �. Fee Is Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 & ,�e wed By January 31 ❑ July 1 R fleceived By July 31 <br /> REM4T <br /> BASE EXPLANATION BILLING REMITTAN E $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED' AMOUNT <br /> FEE <br /> I � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 — <br /> ' OTHER A <br /> Received by Date - Receipt No. Permit No. Issuanc Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 - <br /> L .. ! <br />