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r• Applications Will Be Processed When Submitted Properly Completed. Be Sure To sign Tne Appiwaimn. •t <br /> APPLICATION <br /> (For Non-Transferable,Revocable;and Suspendable) I SEPTAGE <br /> ENVIRONMENTAL HEARTH PERMIT (/ <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in <br /> rthe urisdictional area of the San gag5in cal Health District <br /> 4HldrethLane <br /> McDonald Septic & Bak . Address <br /> Business Name (DSA) <br /> Same <br /> iOwner -T• R. McDonald Address <br /> C <br /> 9 Firm Partners, Addresses and Telephone Numbers 9'57 4027 <br /> CL Business Telephone-No. 1-O 7" ;Emergency Telephone No.. <br /> �. 1 67 <br /> -A Contractor Licence No. Owner - Date <br /> LApplicants Name (Print) T• R•.. McDonald Title <br /> Please check Applicable Category ('14) and Fill in the Required Information _ ' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19:= ` <br /> Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No- <br /> Serial No. CAL. License No- <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address.. <br /> 2. ❑ PUMPER YARD , <br /> For July 1, June 30, 19 "z <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> - r <br /> 3. ❑ PERCOLATION TEST <br /> s R.S.-'r R.C.E.No. <br /> R.S. or R.C.E. Name �- <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job-Address/Location r <br /> • 'Adr, s M <br /> Owner ❑ AGE PLANT <br /> SEPTIC TANK ClESSPOOL .LEACPACK <br /> HING FIELD SEEPAGE PIT 11PACK <br /> OTHE <br /> PERMANENT ❑ TEMPORARY NEW r ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction I, - Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> r <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> 'SIZE: <br /> 9'SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 r les regulatio s o th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ' moo. N,12A, c 0 A-'h.:.w <br /> FOR DEPARTMENT USE ONLY <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH .❑ January 1 8 Received By January 31 ❑ July 1 &ReceivedREMITuty 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 6 df L44>1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Y <br /> Perm N - - I su nce Da Mailed Delivered <br /> Received by Date Receipt No. <br /> eI L COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201— <br />