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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEETAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I Business Name (DBA) McDonald Septic Tank Service Address <br /> zz Owner T.R. MCDOnald` Address Cam <br /> Firm Partners.Addresses and Telephone Numbers <br /> CL Business Telephone No. 931-0497 Emergency Telephone No. 95764027 <br /> Contractor Licence No, _308171 <br /> Applicants Name(Print) T. R. McDonald Title Owner Hate <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION-(FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL.License No. CAL, Licc-ise Renewal No. <br /> Capacity Gal.,Welghts S 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. 13 PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location Test Date/TMme , <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 7-7 ; <br /> caner ' Address <br /> SEPTIC TANK ❑ CESSP L LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 J <br /> Type Construction d Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ 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 /> � — r <br /> i <br /> I hereby certify that.I,have prepared this application and Iha he work will he done in'accordance with San Joaquin County <br /> ordinances,state laws, and I s and ulatt of the San a In Local Health D' rict. <br /> APPLICANT'S SIGNATUREX * \ <br /> FOR DEPARTMENT USE ONLY <br /> 11- Feels Due:❑ ANNUALLY ❑ PER UNIT _❑ PER SITE ❑ EACH ❑ January 1 L,Received By Jarivary 3' ,, ❑ July 1 6 Received By July 31 <br /> BILLING REMITTANCE j REMIT <br /> 'BASF. EXPLANATION AMOUNT DU£ CHECKED <br /> DATE DATE REMITTED t AMOUNT <br /> �s a� <br /> FEE ���`" <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ;Received by .- Date '` -- Receipt No. , Permit No. Issuari Da Mailed: Delivered ' <br /> APPLICXNT—RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PEAMIT/SERVICEI 1001 E.HAZELTON AYE.,P.O.Sam ' *STOCKTON,CA 95201 <br /> -lv.. or 2 <br /> - <br /> ad <br />