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Appllcations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> A ENVIRONMENTAL HEALTH PERMIT 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 /> usiness Name(DBA) McDonald Septic Tank Service Address 4645 Hildreth Lane <br /> iOwner T. R. McDonald Address same <br /> 70 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931- 497 Emergency Telephone No. 957-427 <br /> Contractor Licence No. 308171 <br /> a - <br /> ( Applicants Name(Print) T. R—McDonald _ Title Owrier Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information , <br /> 1. ❑ PUMPER_VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30,•19 �•� Disposal Sites�• t <br /> Description(Make/Yr., Color) _ <br /> Serial No. _ CAL. License No. CAL. Liccnse 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.C.E. Name R.S.or R.C.E.i No. <br /> Test Location Test DatelTime <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> UkSEPTIC TANK <br /> r ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> XPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. r_1 CHEMICAL TOILETS For July 1,-Juni 30, 19 # . <br /> .ype Construction Disposal Site <br /> _..4o. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 `-"' <br /> IA <br /> Operator Name �i Where Certified T __ <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 Than111,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo, y j <br /> / • r <br /> 1 <br /> t / <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County tJ <br /> ordinances, state laws, and rules and regulatio f the an Joaquin Local Health District. 1 <br /> APPLICANT'S SIGNATURE X <br /> WL <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: El ANNUALLY El PER UNIT 1Z PER SITE ❑ EACH Ja Received By January 31 ❑ July 1&Received By July 31 <br /> T $ <br /> REMIT <br /> BILLING REMI <br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED <br /> _ _ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O 5 S 54130 h <br /> Received by Date Receipt No Permit No Is ance to Marled Deliver. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O-Box 2009 STOC .,,CA.. 7 <br />