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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) McDonald Septic Service Address 4645 Hildreth Lane <br /> z Owner <br /> T. R. McDonald Address same <br /> a <br /> Firm Partners, Addresses and Tele hone Numbers <br /> a Business Telephone No. 931497 Emergency Telephone No. 957-4027 i <br /> Contractor Licence No. 308171 <br /> L Applicants Name (Print) T• R. McDonald Title Owner Date <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, June 30, 19 Disposal Sites <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 �nl <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored � <br /> 3. 11 PERCOLATION TEST 09 <br /> F <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address - <br /> SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY [Sr rIEW ❑ 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July!1, -June 30, 19 <br /> r <br /> SIZE: ❑ Less Than 1-,000 Sq. Ft., 11 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.pal <br /> _ <br /> I hereby certify that ILhave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rules andrere�g�ulatiioons of the San Jo a uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> T <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �J/�+ AMOUNT <br /> 4 FEE } Lis (-0 Vt> <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a S <br />` Received by Date Receipt No. Permit No. Issuance Date M led Delivered <br /> I 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009. STOcKTON,CA 95201 <br />