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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) j <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE 6000 ' <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) McDonald Septic Task Seirvice Address_ 4645 Hi 1 Bret,}-1 Vane <br /> ------- <br /> zOwnerT. R. McDonald Address <br /> Samp- <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. - it % Emergency Telephone No. - <br /> Contractor Licence No, 3 0$17 i - <br /> L Applicants Name (Print)T. R. McDonald Title nW niPr Date O.. <br /> Please check Applicable Category (1-7)and Fill in the Required information r Q� <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. '\ r.. CAL. License No. CAL. License Renewal No. t <br /> Capacity, _ Gal.,Weights & Measures No. <br /> Equipfnent',P,aeking Address, I.. 1. t <br /> 2. -❑ PUMPER YARD" <br /> For'July'1, 'June 307)9 , <br /> No. of Vehicles Stored• <br /> No. of-Chem idalgToilets Stored, ; <br /> OERCOLA''Trr,,ION�TES7 s 1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time f C <br /> 4. ❑ SANITATION PERMIT t t <br /> Job Address/Location--- <br /> l\ <br /> Owner Address <br /> SEPTIC TANK ElCESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS'For.July 1, -��" <br /> e 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleanin Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 9 44 r""k. , ? <br /> Operator Name 9I INftere Certified } <br /> Plant Location 4-. E k <br /> LPlant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19i'i��v ; <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY4CLEANING;Chemicals-l7r,�d/Amount/Mo. <br /> ufv`vl f <br /> ,F It <br /> I hereby Certify I have prepared this application an t the work will be' done in accordance with S n Joaquin W�yordinances, state laws, r rules , egul ns of the naqLocal HeaIt Distric <br /> APPLICANT'S SIGNATURE)- F <br /> xr 444 <br /> i 11 eel' If �1 <br /> i FOR DEPARTMENT USE ONLY <br /> wee IS Due; ❑ ANNUALLY - El PER UNIT `*.. ❑ PER SITE _ ❑ EACH ❑ Ja`n0ary 1 &Received FAJa nary 31 0,July 1 &Received By July 31 <br /> f `- BILLING HEMITTANE + $ • ;� -"":'.-REMIT ' <br /> BASE EXPLANATION DATE DATE EMI D AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ; 4 <br /> b� <br /> LESS f ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed. Delivered <br /> "APPLICANT'-RETURN ALL-COPIES TO:'——ENVIRONMENTAL HEALTH-PERMIT/SERVICES «- .-1601 E.HAZELTON-AVE.,.P.O.Box-2003 ..-STOCKTON,CA 95201 i <br /> i+ <br />