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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 I <br /> N Business Name (DBA) McDonald SC 1.0 1 Address 4645 Hildreth Lane ` <br /> i Owner T. R.McDona d Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 931-0497 Emergency Telephone No. - <br /> 402-7 <br /> Contractor Licence No. 308171. <br /> Applicants Name (Print) T. R. McDonald Title Date -+ i <br /> Please check Applicable Category (1-7) and Fill in the Required Information '- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) a <br /> Serial No. CAL.License No. CAL. Liccnse Renewal No. f <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. 11 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.G.E. No. <br /> Test Location Test Date/Time 1 <br /> 4. ❑ SANITATION PERMIT <br /> 7— <br /> Job Address/ ncntinn <br /> Owner - $ { <br /> SEPTIC TANK f CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE LA <br /> NT <br /> L� PERMANENT ❑ TEMPORARY NEW ❑ 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) <br /> & ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> I Plant Capacity No. Units Served <br />'i 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 4 ❑ 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 /> iI ordinances, state laws, and rule5i regulations of tre San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ?UiVT <br /> FEE ' <br /> s <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> Received by Date Receipt No. Permit No. lalsuance Tate Mailed Delivered <br /> 1 - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PIER MITISERVICES 1901 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />