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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE O <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> s y Business Name (DBA) McDonald Septic Service Address <br /> a Owner T. R. . McDonald Address' same <br /> Firm Partners, Addresses and Telephone Numbers. <br /> CL a Business Telephone No...931-0497 _ Emergency Telephone No. 957-4077 <br /> r -Contractor Licence No. 30$171 <br /> I LApplicants Name (Print) T. R.. McDonald Title -__ O>iairiPr Date <br /> Please check Applicable Category(1-7) an(d Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) „k <br /> For July 1, June 30, 19{ ( Disposal Sites <br /> Description(Make/Yr., Color)..-`., N., <br /> N- i <br /> Serial No. 4- CAL'. L cense'No CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures,Nro. <br /> Equipment Parking Address _. _ <br /> 2. ❑ PUMPER YARD <br /> t For July 1, June 30, 19 <br /> No. of Vehicles Stored _1 <br /> No. of Chemical Toilets Stored- l <br /> 3. ❑ PERCOLATION TEST"' U <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. W <br /> Test Location Test Date/Time <br /> 4. 11 SANITATION PERMIT � _So <br /> Address/Location I <br /> KO ner Address P- 611 <br /> SEPTIC TANK El CESSPOOL., r.�LEACHINGFIELD•--❑-SEEPAGE-PIT' -0` ::.RACK GE PLANT <br /> i PERMANENT 1:1 TEMPORARY ! L3 NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Type ConstructionDisposaf.Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name p Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ' 1Y" <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 GLEANING;-Chemicals Used/Amount/Mo. <br /> L <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> f ordinances, state laws, and rules and regulatio he San Joaquin Localalth District. <br /> l APPLICANT'S SIGNATURE X <br /> r � <br /> r 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 /> s <br /> i L BILLING, _ REMITTANCE REMIT <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT pUE CA�EC1K�D <br /> A / <br /> FEE " yI <br /> .,.-. , <br /> LESS �� <br /> PRORATION A All <br /> S PLUS <br />} PENALTY •'� <br /> i; OTHER „r.S ...--•'�'" - <br /> OTHER <br /> rig <br /> Received by Date - ? Receipt No.,"j Permit No. Issuance Date Mailed Del iv ed <br /> - ''APPLICANT—RETURN ALL COPIES.TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STO KTON,CA 95201 . <br />