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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> y vitor Non-Transferable, Revocable, and SuspendavIll <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 SQptl Tanlr Sar e, Address 464.5 Hl ldrpth I anp <br /> 4 Owner T R McDonald Address Sams <br /> :u,.Firm Partners,Addresses and Telephone Numbers <br /> 'A. Business Telephone No. 931-0497 <br /> Emergency Telephone No. 9-57-4027 to <br /> �Contractor Licence No. 308171 I <br /> L Applicants Name (Print) T. R. McDonald Title Ownpr Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) D <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License 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. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT r C <br /> Job Address/Location <br /> Owner Add ss <br /> J�SEPTIC TANK ❑ CESSPOOL LEACHING I16f ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> r l'C[+ PERMANENT ❑ TEMPORARY NEW '�C� ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) 0 <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 5 <br /> 7. 11 LAUNDRY For July 1,-June 30, 19 <br /> S16: ❑ 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 culeaand regulations f t e an Joaquin�al H th District. <br /> APPLICANTS SIGNATURE X r�JH 1 <br /> �- FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 16 Received By January 31 ❑ July 1 d Received By July 3' <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 45 Ckp, L <br /> LESS �� <br /> PRORATION i -14 <br /> P PLUS hL <br /> PENALTY <br /> OTHER o <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issue ce Date Marietl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA W. <br />