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APPLICATION <br /> (For <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> 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 /> Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildroth Tan <br /> i-Owner T. R. McDonald Address Storkton, ra 95212 <br /> irm Partners, Addresses and Telephone Numbers <br /> : usiness Telephone No. 931-0497 Emergency Telephone No. 957-417177 <br /> Contractor Licence No. 309171 — <br /> 1 4pplicants Name (Print) T R McDonald Title Owner Date I <br /> 60lease check Applicable Category (1-7)and Fill in the Required Information „( <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> 'or July 1, June 30, 19 Disposal Sites J <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 /> 'r+1. ❑ 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. No. <br /> Test Location Test Date/Time <br /> daa4. ❑ SANITATION PERMIT D <br /> Job Address/ ocation <br /> Orcccc����wns Address <br /> � JSEPTIC TANK DCESSP06L LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 5 <br /> Type Construction Disposal Site <br /> r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ 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. FL <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. / <br /> 1 <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 rul nd regulation5li(.aithe San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> �LA 00 <br /> Oli �- <br /> FOR DEPARTMENT USE ONLY <br /> -- FM Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ` <br /> BASE EXPLANATION BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> ( <br /> FEE rL <br /> LESS <br /> ` PRORATION <br /> PLUS <br /> } PENALTY <br /> L , OTHER <br /> ` OTHER <br /> Received by Date Receipt No. Permit No. Isin a cet Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON .,P.O.90.2009 STOCKTON,CA 95201 <br /> l r.fl <br />