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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> p (For Non-Transferable, Revocable,and Suspendable) 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 /> y Business Name (08A) McDonald Septic Tank Service Address 4645 Hildreth Lane <br /> z Owner T. R. McDonald Address Stockton Ga 95212 I <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. —931-0497 Emergency Telephone No. 957-4027 c�11 <br /> Contractor Licence No. 081 1 y <br /> L Applicants Name (Print) T. R. McDonald Title Oder Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information d <br /> 1Ii f❑ PUMPER-VEHICLE P.FRMIT_ ,REGISTRATION_(FOR�'ACH�VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) � <br /> Serial No. t I CAL. License Na: fll . _CAL. Licznse Renewal No. <br /> I'llCapacity t f Gal., Weights & Measure= No. F' <br /> Equipment Parking Address <br /> 2. 11 PUMPER YARD r 1 �—.�- --.sa.�' ' -- '" a <br /> For July 1, r June 30, 19 <br /> No. of Vehicles Stored / ti <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name f t R.S. or R.C.E. No. <br /> ^ '"�` Test Date/Time t <br /> Test Location° ) <br /> 4. ❑ <br /> SANITATION PERMIT y I 1V, <br /> Job Address/Location <br /> 'Address' <br /> Owner <br /> ❑ SEPTIC TA C POOL ❑ LEACHING IELD' i] SEEPAGE PIT ❑ PACKAGE PLANT t <br /> ❑ PERMANENT ❑ T MPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETSFor July 1,-June 30, 19 1� <br /> Type Construction J_. - Disposal Site -No. of Units ) Equipment Storage/Cleaning Location(s) y <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator N a i Where Certified - <br /> Plant Location <br /> Plant Capacity i 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. 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> z <br /> I hereby certify that I have prepared this app licfff <br /> Zan <br /> that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws�andr re I ions the San Joaquin Loca Healt istrict. <br /> i, <br /> APPLICANT'S SIGNATURE X- --- -- - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH ❑ January 1 &9eceived 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 l V <br /> PRORATION ' <br /> PLUS <br /> -PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> 6693 5-8�1 <br /> M Received by Date Receipt No. Permit Ne. llssu ce Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .O.Box 2009 STOCKTON,CA 95201 <br />