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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T�v <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPPAGE <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 Hildreth Lane <br /> i-; i Owner :T. R. McDonald Address Stockton, Ca 95212 <br /> Firm Partners,Addresses and Telephone Numbers <br /> a` Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <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) �� •� 5y <br /> For July:1, June 30,'19 014.0satl Sites,l1� <br /> Description(Make/Yr. Color) t— <br /> owner's Name <br /> t —Address-v`, �' License Nc� Ph n ' <br /> Equipment Parking Address <br /> --2. ❑ PUJNPER YARD I <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored ,•L ,+, <br /> No. of Chemical Toilets Stored <br /> 3- ❑°PERCOLATION TEST •--�► <br /> R.S.or R.C.E.Name <br /> Test Location --re Date/T <br /> 4. ❑ SANITATION PERMIT I � <br /> Job Addre Location ' <br /> Owners I Address <br /> 1 J�SEPTIC TANK ❑ CESSPIQVOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPOF(/1RY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-Ju a 30, 19r <br /> Type Construction Disposal Site, f ` <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name /111 <br /> I + Where Certified <br /> Plant Location (t <br /> Plant Capacity. — No.Units Served V <br /> T. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this application and that the.work will be done in ac ance with San Joaquin County <br /> ordinances. state laws,an rut nd egulat' of the San Joaq n Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT UiE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ EACH ❑ January 1&Received By January 31 ❑ July 1 8 Received By July 31 <br /> t <br /> r BILLING REMITTANCE 3 REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED 1 <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> V I <br /> LESS " <br /> PRORATION rl� <br /> PLUS 4 <br /> PENALTY - <br /> OTHER a <br /> - r <br /> OTHER <br /> 75 <br /> Received by - Date Receipt No. Permit No aeuance ate Mailed Deliveretl <br /> APPLICANT-.:.RETURN ALL COPIESnTO:.'. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601. HAZELTON AVE.,P.O.hoe 2009 STOCKTON,CA 95201 1 <br /> I i <br />