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Applications.Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ..wror Non-Transferable, Revocable, and SuspendabvV) <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 c Tank Service Address 4645 hsi ldrPrT, Lane <br /> ? Owner T. P, . MC oval d Address 4645 hi 1 dss t], 1 ana <br /> =irm Partners, Addresses and Telephone Numbers <br /> 3usiness Telephone No. 931-0497 Emergency Telephone No. 757-4027 <br /> Contractor Licence No. 308171 <br /> applicants Name (Print) T_ R_ T,ic!)nna 1 d Title )Wrier Date <br /> _Tease check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Por July 1, June 30, 19 Disposal Sites <br /> )escription(Make/Yr., Color) <br /> 'Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> quipment Parking Address <br /> .r. ❑ PUMPER YARD A <br /> For July 1, June 30, 19 '�\ <br /> No. of Vehicles Stored <br /> Jo. of Chemical Toilets Stored .-.1 <br /> 3. ❑ PERCOLATION TEST C <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> est Location Test Date/Time <br /> �. ❑ SANITATION PERMIT <br /> Job Address/Location CJ <br /> )wner Address <br /> ;k <br /> SEPTIC TANK CESSPOOL LEAC NG FIELD .SEEPAGE PIT 11 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> F. CHEMICAL TOILETS For July 1,-June 30, 19 <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 /> )perator Name Where Certified <br /> _'lant Location <br /> Plant Capacity No. Units Served <br /> 1. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 'IZE: ❑ 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 rules and regulations oft an Joaquin Local Health strict. <br /> `APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT WIPER 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. �it No. issuance Date Mailed Delive ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 95201 <br />