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`Applications Will Be Processed When Submlited Properly Completed.Be Sure To Sign The Application. APPLICATION (For Non-Transferable,Revocable,and Suspendable) ENVIRONMENTAL HEALTH PERMIT SEPTAGE LIQUID WASTE Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District a Business Name (DBA) McDonald) optic Tank—Sex irte—Address.- 4645 u:ia,,eth_Lane z Owner T. R. McDonaldAddress Same JU Firm Partners, Addresses and Telephone Numbers -- -- aBusiness Telephone No. __ 931-0497 Emergency Telephone.No.. 957-4027 Contractor Licence No. 308171 Applicants Name (Print) T. R. McDonald --_ Title Owner__ Date Please check Applicable Category (1-7) and Fill in the Required Information O 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) I I For July 1,_ June 30, 19 Disposal Sites . Description(Make/Yr.,Color) Serial No. __- tiI%- _CAL.License No. CAL. Licz.-se Renewal No. �! Capacity _ Gala Weights &Measures No. Equipment Parking Address ` L':• 2. ❑•PUMPER YARD For July 1, `` June 30F19 v � r.. Y No. of Vehicles Stored �•� �� r __ �'-- ' No. of Chemical Toilets Stored - 3. ❑ PERCOLATION TESTI t R.S.or R.C.E. Name _ R.S.or R.C.E. No. _..._.. Test Location Test Date/Time- 4. ate/Time 4. ❑ SANITATION PERMIT t Job Address! ocatio ---- r Owner !REPAIR ❑ PACKAGE PLANTSEPTIC NK ❑ C SPOOL �LEACHIN IELDGE PITPERMANENT ❑ TEMPORARY ❑ Ew ❑ OTHER h S. ❑ CHEMICAL TOILETS For July 1. -June 30, 19 1 _ Type Construction Disposal Site---- _. No. of Units _ Equipment Storage/Cleaning Location(s) -ID 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 S Operator Name Where Certified Plant Location Plant Capacity No. Units Served _ 7. ❑ LAUNDRY For July 1,-June 30, 19 SIZE: ❑ Less Than 1,000 Sq. Ft.. ❑ More Than 1,000 Sq. Ft. ❑ DRY CLEANING.Chemicals Used/Amount/Mo. - I hereby certify that I have prepared this application and that the work will be done in accordancelw 4, n Joaquin County ordinances, state laws,and rules and regula ions of the Sar,Joaquin Local Health District. 111 r��t! APPLICANT'S SIGNATURE X -• C U + FOR DEPARTMENT USE ONLY j Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ Jandary 1&n cei d By Ja uZIC3 .hily' &Received By juiy`s' '— — — REMIT BASE FXPLANATION BILLING AAT 3 AMOUNT DUE CHLCKLG DAZE EMI AMOUNT _..._FEE LESS —-- PRORATION PLUS — PENALTY OTHER OTHER Received by Date Receipt Nu. FT,;rmrt N:,. Issuance Dale mined Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O. 2009 �KTON,CA 201 3 f C)