Laserfiche WebLink
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 /> t Application is hereby made to carry on business in the jurisdictional area.oi the San_ Joaquin Local Health District <br />' rBusiness Name (DBA) McDonald Se tic & Backhoe Address 6 Hildreth ��Lane <br /> a Owner. <br /> T. R. ,McDonald Address Same <br /> J Firm Partners, Addresses and Telephone Numbers 957-l+07 <br /> I IL Business Telephone No. 931-0.4'97 _ Emergency Telephone No. <br /> f -A Contractor Licence No. 3 3 3 6 7 <br /> � <br /> Applicants Name (Print) T. n. <br /> R.. 'MCDoald,. Title Owner~ Date <br /> Please check Applicable Category (1-7)and Fill in,the Required.Information,,, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR-EACH2NEHIC�LE) <br /> For July 1, - June 30, 19 _—= "Disposal Sites O <br /> I <br /> Description(Make/Yr., Color) - T` <br /> CAL. License Renewal <br /> Serial No. <br /> CAL License No. <br /> Capacity Gal.-,--Weights-&.Measures-No. <br /> Equipment Parking Address - N <br /> 2. ❑ PUMPER YARD 3 <br /> For July 1, June 30, 19 <br /> .l <br /> No. of Vehicles Stored ti , <br /> -No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location t Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> � I <br /> Job Address/Loc tion <br /> r <br /> AddressOwner <br /> _ <br /> ❑ SEPTIC TANK 11CESSPOOL ' `LEACHING-FIELD ❑ SEEPAGETIT- , ❑PACKAGE PLANT{ <br /> 1:1PERMANENT 1:1TEMPORARY ❑,NEW REPAIR ❑ OTHERS ----------. <br /> 5. 0 CHEMICAL.TOILETS For July 1�'-June 34, 19 <br /> Type Construction. <br /> 4 Disposal Site r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11 "PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator NameI Where Certified - <br /> Plant Location I <br /> No. Units Served <br /> Plant Capacity r f <br /> 7. © LAUNDRY For July 1,-June 30, 19 1 } <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000.Sq. Ft, _ t 1 t <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo... -- Y <br /> i <br /> y. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> sordinances;---state laws,Mandul <br /> an regal softhe San Joaq Local Health' "District-. <br /> APPLICANT'S SIGNATUREX <br /> { <br /> FOR DEPARTMENT USE.ONLY t <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS _.- <br /> PRORATION <br /> PLUSN <br /> PENALTY `-` <br /> OTHERC <br /> OTHER <br /> toe <br /> Received by Date `Receipt No, Permit No. I uance bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH P�E,RAMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Roc 2009 STOCKTON,CA 95201 <br />