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Applications.Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> Por Non-Transferable, Revocable,and Suspendamee) SEPTAGE <br /> 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 /> „�6usiness Name (DBA) MCDonald Septic Tank Service Address 4645 Efi 1drPt=1 LanI- <br /> = Owner T. R. McDonald Address 4645 Ni 1 d-pet-h `1.anP <br /> a <br /> =irm Partners, Addresses and Telephone Numbers <br /> 3usiness Telephone No. 431-0497 Emergency Telephone No. -097-4097 <br /> Contractor Licence No. 308171 <br /> 4pplicants Name (Print) T R KcDonal d Title �I er Date <br /> Dlease check Applicable Category (1-7)and Fill In the Required Information <br /> ~I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> ')escription(Make/Yr., Color) <br /> -. erial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> quipment Parking Address <br /> Z. ❑ PUMPER YARD C <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Vo. of Chemical Toilets Stored , <br /> "-3. ❑ PERCOLATION TEST 1 <br /> R.S.or R.C.E. Name R.S. or R.C.E.No. <br /> fest Location Test Date/Time <br /> ,tet. ❑ SANITATION PERMIT <br /> Job Address/Location L <br /> Owner Address <br /> SEPTIC TANK P CESSPOOL LEACHTNG FIELD .SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 12KN 12KEW ❑ REPAIR ❑ OTHER <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 1 <br /> Type Construction Disposal Site <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. Ft. <br /> "L7 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of 991,San Joaquin Local Health strict. <br /> !APPLICANT'S SIGNATURE X <br /> .. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT lot.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 /> DATE DATE REMITTED AMOUNT <br /> FEE �� %✓ `' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Per it No. issuance Date Mailed Delive ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STO TON,CA 95201 <br />