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Applications Will Be Processed When Submitted Properly Gampleiea. ceaide 1W ^Mr••- <br /> APPLICATION L <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> "t 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 /> O Business Name (DBA) McDonald Septic Tank Service Address 4645 HZl--dreth Lane <br /> Z owner T.R. McDonald Address_ StocktonCa 95212 <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers 957-4027 <br /> a 931-049 Emergency Telephone No. <br /> 'a Business Telephone No. <br /> Contractor Licence No.3C <br /> 8171. <br /> Applicants Name (Print) M n d TitleOwn <br /> Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information r_ <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. GAL. Lice lse Renewal No. <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. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT , <br /> Job Address/Locatio } <br /> Y <br /> Owner Address <br /> 13 SEPTIC TANK ❑ C SPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER r- <br /> 5. ❑ CHEMICAL TOILETS For July 1, .June 30, 19 D <br /> Type Construction f► Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity i 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 /> w.. <br /> I hereby certify that I have prepared this applicatiod that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a regulations of th Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Oni <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 /> GATE DATE REMITTED AMOUNT <br /> ao �L <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS J <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssuanc Date fled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH P€RMIT/SERVICES 1601 E.HAZELTON AV .Box 2009 ;To TON,CA:201 <br />