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I Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br />` (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT l""" SEPTAGE <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) McDonald Septic Tank Service _ Address 4645 Hi7ydret <br /> aOwner T. R. McDonald Address 5tockto-n, _451 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL a Business Telephone No. 931-0497 Emergency Telephone No._. _5 7=4Q2] <br /> Contractor Licence No. 308171 9 <br /> LApplicants Name (Print) T. R. McDonald Title nwnPr _ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information p 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites WWW <br /> Description(Make/Yr., Color) <br /> Serial No. 'CAL. License No. CAL. License Renewal No. "r <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.G.E. Name R.S. or R.C.E. No. <br /> Test Location pq Test Date/Time <br /> 4. ❑ SANITATION PERMIT 001, <br /> Job Address/Location <br /> Owner 4fla Address <br /> ASEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 'NEW REPAIR ❑ OTHER <br /> 5. 11CHEMICAL TOILETS For July 1, -Jlune 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 13. ❑ 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 /> SIZE- ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> - J � <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, and rules and regulto s of the San Joaqu' Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece <br /> PW By January 31 El July 1 &Received.8y Jury 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUN'TDUE CHECKED 5 <br /> f� DATE DATE REMITTED AMOUNT <br /> FEE <br /> �u� <br /> LESS <br /> PRORATION <br /> PLUS J k <br /> PENALTY k <br /> OTHER t <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permit No. an Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.-H TON AVE"P:O.`Bov 2009 STOCKTON,CA 95201 - <br />