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) <br /> 3l ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the j risdictional area of the San Joaquin Local Health District <br /> v;Business Name (DBA) McDonal d Septi.c Tank Service Address 4645 Hi l dreth Lane <br /> z Owner T. R. McDonald Address Stockton, Ca 95212 <br /> C <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> a <br /> Contractor Licence No. 30171 <br /> Applicants Name (Print) L R. Mrnonald Title Owner Date <br /> I <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 1` <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 <br /> No. of Chemical Toilets Stored <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 <br /> Owner Address. <br /> 11 SEPTIC ANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY —94NEW 1R REPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ��/ � f / 39�f 42 5' <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 /> Operator Name Where Certified <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 pppltcatkion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a regul ns of the San Joaquin Lo i H th District. <br /> APPLICANT'S SIGNATURE X 03 <br /> ILT <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED <br /> p AMOUNT <br /> FEE `� � l.�\ � � <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY Vi <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Irssuanke Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009, STOCKTON,CA 95201 - <br /> f <br />