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} � Applications WillBe Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) $ PTAGE— - a> <br /> ENVIRONMENTAL HEALTH PERMIT �" b <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> McDonald Se tic Tank SerViCe Address 4645 Hildreth Lane <br /> y Business Name (DBA) 4645 Hildreth Lane <br /> P) <br /> Owner_ T • R• MCDId Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers _ 2 <br /> 0. Business Telephone No. — Emergency Telephone No. <br />• 171 <br /> �Contractor Licence No. 0 mPY Date <br /> Applicants Name (Print) Title <br /> W <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, Disposal Sites June 30, 19 P <br /> Description(Make/Yr., Color) <br /> ' CAL. License Na. CAL. License Renewal No.Serial No. I <br />' <br /> Capacity Gal., Weights &Measures No. <br /> t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 v 'I <br /> No. of Vehicles Stored . <br /> No. of Chemical Toilets Stored <br /> I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ASEPTIC TANK ❑ CESSPOOL LEACHING FIELD Lk SEEPAGE PIT ❑ PACKAGE�PLANT� <br /> PE ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i <br /> fi. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a r and regulati f the San Joaquin Lo Health District. <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv d By REMITuly 31 <br /> P BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> t FEE <br /> St LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> v 1 OTHE.: <br /> k <br /> OTHER <br /> �r ? <br /> ' Date Receipt No. er it No. Is anc Date Mailed De1iv re <br /> •' - Received by <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCISTON,GA 95291 <br /> �: '. APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />