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<--.-'-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> APPLICATION <br /> (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 /> V) Business Name (DBA} McDonald Septic Tank Service Address 4645 Hildreth Lane � <br /> r,same-. <br /> z Owner T. R. McDonald Address _ i <br /> jFirm Partners, Addresses and Telephone~Numbers <br /> a - Emergency Telephone No. _/+�27 <br /> CL Business Telephone No. <br /> d 7. <br /> Contractor Licence No. <br /> Applicants Name {Print) T R. McDonald _Title Owner Date <br /> L/ <br /> Please check Applicable Category.(11-7)and Fill in the Required Information s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH:VEHICLE) - <br /> For July 1, June 30, 19 Disposal Sites . « <br /> Description(Make/Yr., Color) <br /> ""-CALL.License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & M_easures 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 r� <br /> R.S. or R.C.E. Name R.S, or R.C.E. No. ., A <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT s� 4 4 4t 1co <br /> Job Address/Location <br /> Owner Address <br /> SEPTIC TANK.. ❑ CESSPOOL`'' EACHING FIELD ❑ PACKAGE-PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER �... 7T <br /> 5. ❑ CHEMICAL TOILETS "For July-1, --June 30, 19Disposal Site <br /> �F <br /> Type Construction i��,�� p <br /> No. of Units ��'' puipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENTLT` For July 1, =June 30, 19 <br /> Where Ce <br /> Operator Name _ rtified. <br /> ;l <br /> Plant Location `r <br /> Planf:Capacity No. Units"Served " <br /> 7. ❑'[LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 9 SIZE: `t" ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l ... <br /> I hereby certify that I have prepared1his application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws, an l-015.and reguls of the San Joaquin Local Health District. <br /> M <br /> APPLICANT'S SIGNATURE X <br /> FOR-DEPARTMENT USE ONLY <br /> Fee,as Due: ❑ ANNUALLY._ ❑ PER UNIT +� PER SITE ❑ EAC1-f C1 January 1 &Received By January 31 ❑ Julyi &Received By July 31 t <br /> _ . t <br /> REMIT ' <br /> BILLING RE t1TANCE $ 1 <br /> BASE - E PLANATION AMOUNT DUE 3_ V CHECKED <br /> DATE - DA-E REMITTED AMOUNT <br /> FEE <br /> LESS . <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER I{ <br /> OTHER <br /> Date Receipt No. �...Permit No. Issuance Date, - Mailed Delivere <br /> Received by <br /> k HAZELTON AVE.,P.O.Box 2009 STOCK N,CA-9 01 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. /J} <br />