Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Compiemo. or aurc 1V-•a• - t- - <br /> APPLICATION <br /> (For Non-Transferable, 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 Joaqui In Local Health District <br /> McDonald Se tic Tank Service Address 4645 Hildreth Lane <br /> N Business Name (DBA) Stockton Ca 95212 <br /> Ii- Owner_ T. R. McDonald Address <br /> R <br /> 0 Emergency Telephone No. <br /> Firm Partners, Addresses and Telephone Numbers 957-4027 <br /> aBusiness Telephone No. 9,: 4 7 <br /> �Contractor Licence No. $1 1 <br /> �Applicants Name (Print) <br /> T. R. McDonald f Title Owner Date <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) CAL. Lic-nse Renewal No. <br /> Serial No. CAL License 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. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK �10--] E�SSP L LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT 11TEMPORARY: <br /> NEW r REPAIR 11 OTHER ". <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 y <br /> Type Construction Disposal Site i <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 1 <br /> Plant Location E <br /> No. Units Served <br /> Plant Capacity <br /> i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 J -7� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> 1 '{{ <br /> f <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ides a d regulations of^San Joaquin Local ealth District. <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 ❑ Juiy 1 &ReceivedBy July 31 <br /> REMIBASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> PATE DATE REWTTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> v <br /> PLUS l <br /> PENALTY ` <br /> OTHER <br /> tr <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuanc Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 570CKTON,CA 952 <br /> 01 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />