Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. b <br /> a APPLICATION b <br /> (For Non-Transferabie, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> iy ic v <br /> business Name (O■A) CDonald Set ' Address I <br /> i Owner T. R. McDonald Address' <br /> . 7 Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 931-0497 Emergency 957-4097 <br /> Telephone No. _ -- j <br /> k < <br /> Contractor Licence No. 308171 <br /> L Applicants Name (Print) Title QTrfLPtts Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Y , <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,"Color) <br /> No. CALrtScw Ise Renewal.No.. <br /> Serial No. CAL. License �- <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Addres''s - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> r 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. Na. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc <br /> w.ner -- <br /> SEPTIC TA CESSPOO EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> i <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Jun 30, 19 "4 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> t, 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where,Certified <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity I <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that awor will be done in accordance with San Joaquin County <br /> i <br /> ordinances, state la:�?tT o the San J qui)Lo�al Health District. <br /> { APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is-Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ' ❑ EACH EI January 4 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ,. _ - _ REMIT <br /> ASE EXPLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> DATE,' GATE REMITTED AMOUNT <br /> FEE <br /> - <br /> tr. PRORATION <br /> i PLUS - {' <br /> PENALTY <br /> v <br /> OTHER <br /> OTHER <br /> Received by Date <br /> 1601 Receipt No. �.Permi 'NO,.__A Issuance Dae Mailed re <br /> APPLICANT—RETURN ALL•-COPIES TO: ENVIRONMENTAL HEALTH PEFIMITJSERVICES. E.HAZELTQN AVE.,P.O.Box 2009 STOCK ON,CA 85201 <br />