Laserfiche WebLink
-- _ __ .. <br /> properly1L,0"1IJ11 <br /> Applications WIII Be Processed When SuAPPLICATION <br /> {For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEAL-TH FERMIS <br /> ""� LIQUID WASTE al He It District <br /> w' �j 1�dreti ane <br /> 1 � made to carryon busines in thejurisdictional area of the Sa <br /> Application is hereby ervl ce Address <br /> McDonald Septic tank Same <br /> N Business Name (DBA) .� R. MCDOnal d Address <br /> z Owner Telephone No. 9� ~ <br /> A _ Emergency <br /> firm Partners, Addresses and Telephone Numbers <br /> 97 <br /> OCL, Business Telephone No.—� 308171 Owner Date <br /> Title <br /> a Contractor Licence No. R. McDollal d <br /> 4 Applicants arae <br /> (Print) ired information <br /> Please. eck Applicable Category (1-7)and Fill in theRequ <br /> FOR EACH VEHICLE)- <br /> C) <br /> EHICLE) <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (Disposal Sites. <br /> For July 1, June 30, 19 <br /> II CAL.. Licc'Ise Renewal No. <br /> Description(Make/Yr., Color) <br /> j CAL. License No. <br /> I Serial No. Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored R.S. or R.C.E. No. <br /> 3. ❑ PERCOLATION TEST' - <br /> R.S. or R.C.E. Name Test Date/Time <br /> '9-0 I <br /> _Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locate n ❑ PA KAGE PLANT <br /> CESS <br /> Owner ❑ POOL LEACHI G FIELD SEEPAGE PIT ❑ OTHER <br /> SEPTIC TANK NEW ❑ REPAIR ._ ... -. <br /> C3TEMPORARY <br /> PERMANENT 19 ' <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, <br /> Disposal Site <br /> Type Construction Equipment Storage/Cleaning L0000n(S) <br /> } No. of Units i, -June 30, 19 Where Certified <br /> i 6. ❑ PACKAGE TREATMENT PLANT For July <br /> Operator Name <br /> f plant Location No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1, -June 30,1gMorThan1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq, Ft., <br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> rtif that I have prepared this applicatien d that the work an Joaquin LocallH alth District ll done 'in accordance with San Joaquin County <br /> l I hereby ce y re at'ons t <br /> ordinances, state laws, and r !e <br /> APPLICANT'S SIGNATURE X <br /> --------------- <br /> fFOR DEPARTMENT USE ONLY ❑ July t &Received BY JUIy 31 <br /> I ❑EACH ❑ January 1 &Received By January 31 REMIT <br /> PER UNIT ❑ PER SITE CHECKED <br /> j Fee Is Due: ❑ ANNUALLY ❑ REMITTANCE AMOUNT DUE AMOUNT <br /> BILLING REMITTED <br /> BASE EXPLANATION DATE DATELIS <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS J� <br /> PENALTY QIS <br /> OTHER <br /> OTHER <br /> k _ = Delivered <br /> Permit No. <br /> w Issuance Date Mai d <br /> - STOCKTON,CA 95201 <br /> Date Receipt No. 1601 f.HAZELTON AVE.,P.D.90 <br /> n�� Received by ENVIRONMENTAL HEALTH PERMITlSERYICES- <br /> +F' k— APPLICANT—RETURN ALL COPIES TO: .-.. <br />