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Applications Will Be Processed When Submitted Properly Completed. Be Sure a Ig I <br /> i APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGO <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f' ! LIQUID WASTE <br /> i Application is hereby made to carry on business in the jurisdictional area of the4645o Hiin ldreth ealth Laneistrict <br /> McDonald Septic Tank Service Address . <br />� �Business Name (DBA) Stockton, Ga 95212 <br /> a Owner T• R. McDonald . Address <br /> Firm Partners, Addresses and Telephone Numbers 957-•4027 <br /> a Business Telephone No. <br /> 931-0497 Emergency Telephone No. <br /> �Contractor Licence No. 308171 Title ()wn Date <br /> L Applicants Name (Print) T• R. MC -Donald <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> . p� <br /> l 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> f <br /> ,,) �"Dis osa;Sites _ <br /> For July 1, June 30,-A9-=� p <br /> Description(Make/Yr., Color) CAL, Liccr"sa Renewal No. <br /> Serial No. CAL. License No. <br /> ` v <br /> Capacity E Gal.,Weights & Measures No. e <br /> r0 ` <br /> Equipment Parking Address ` <br /> 2DPUMPER YARD <br /> For Juiy.1,� June 30, 19 J <br /> R. k <br /> I No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. !(r <br /> R.S. or R.C.E. Name 1- <br /> Test Location Test Date/Time p , <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ ocation <br /> Owner Address <br /> SEPTIC TANK 11 CESSPOO LEACHING FIELD 11 SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ REPAIR ❑ OTHER <br /> kPERMANENT 13 TEMPORARY NEW F� [� <br /> i. 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 , <br /> L Type Construction Disposal Site r <br /> F No. of Units <br /> Equipment Storage/Cleaning Location(s) <br /> B. C1 PACKAGE TREATMENT PLANT I For July 1, -June 30, 19 <br /> r, C`: Where Certified. ' <br /> Operator Name <br /> t Plant Location ., __��_-- -•-+r*�+ <br /> Plant Capacity No.Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 More Than 1,000 Sq. Ft. <br /> t ❑ DRY CLEANING, Chemicals Used/Amount/Mo. �rf , <br /> 1 <br /> I hereby certify that 1 have prepared this applicatiori an the work will be done in accordance With San Joaquin County <br /> ordinances, state laws, and rules 4p4egulations of th S J quin Local Health Di ct. <br /> APPLICANT'S SIGNATURE X <br /> ( FOR DEPARTMENT.USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 <br /> July 1 &Received EMITBy uIy 3i <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASF EXPLANATION DATE - DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER - - /- <br /> OTHER <br /> 4 <br /> ReceivedbyDate Receipt No. <br /> er it No. issuance slate �1u1ai1ed e ivere <br /> _ APPLICANT—RETURN ALL COPIES TO'- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1'o.E. AZELiON"AYE.,P.O.Boy 2009. STOCKTON,CA 95201 <br />