Laserfiche WebLink
j Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .; APPLICATION -9 <br /> (For Non-Transferable, Revocable, and Suspendable) ) <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 /> yBusiness Name (DBA) McDonald Septic Tank Service Address 4645 Hildreth T,Ane } <br /> I- Owner T . 'R. McDonald Address Qqme <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers _4027 Emergency Telephone No. <br /> a. Business Telephone No. 1- g y }— <br /> Contractor Licence No. 308171 y <br /> Applicants Name (Print) T R McDonald Title Date U� <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address P <br /> 2. ❑ PUMPER YARD j <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ti <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location est Date/Time <br /> 4. ❑ SANITATION PERMIT Ji9K <br /> Job Address/Loc 'on Y" <br /> Owner Address <br /> ❑ SEPTIC TAN ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR 11OTHER <br /> 5. 13CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this applicatio d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ul nd re tions of S Joaquin Local Health Distri <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 &Recewed By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> F DATE DATE R ITTED AMOUNT <br /> EFEECJ O <br /> +I <br /> � 3 1ct 3 <br /> Received by Date Receipt N. Permit o- Issuance Date Mailed �belivered J �j*�3 <br /> ii _ APPLICANT--RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O:Boa 2409 s. STOCKTON,CA 95201 <br /> 1 <br />