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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 Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <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 Tank Service Address 4645 Hi 1 dreth Lane <br /> z Owner T. R. McDonald Address Same <br /> Firm Partners, Addresses and Telephone Numbers �?s <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-41197 <br /> Contractor Licence No. 308171r <br /> Applicants Name (Print) T. R. McDonald __ Title (honer Date V\ <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, License Renewal No. ' <br /> Capacity Gal., Weights & Measures No. } <br /> Equipment Parking Address , <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored 1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location r <br /> Owner Add ss f <br /> 4SEPTIC TANK ❑ CESSPOOL LEACHING ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Q <br /> Operator Name Where Certified <br /> Plant Location r <br /> Plant Capacity No. Units Served S <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 } <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ <br /> 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 /> ordinances, state laws, and ule d regulations of t e an Joaquin Local H th District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> RENnT--- ` <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> L� AMOUNT <br /> FEE I� + & is <br /> LESS /J <br /> PRORATION <br /> �+ PLUS t ` <br /> PENALTY <br /> OTHER f 99r <br /> OTHER t <br /> b7'\ <br /> Received by Date Receipt No. Permit No. I Issuallce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201�}q <br />