Laserfiche WebLink
r 9 <br /> Applications Will Be Processed When Submitted Properly Completed. Be Suir hp Sign The Application. - - <br /> APPLICATION <br /> w � (For Non-Transferable, Revocable, and Suspendable) <br /> i ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) McDona ticSPrvi_�ro Address l� d�Eth s <br /> aOwner Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. <br /> 997-4097 <br /> Contractor Licence No. 308171 <br /> �Applicants Name (Print) T.R . McBOnald Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br />?. 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �r <br /> t For July 1, June 30, 19 : I Disposal Sites <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 4 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <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 p <br /> Job Address/Location �j <br /> Owner Address <br /> ❑ SEPTIC T' ❑ C SSPO LEACHING ELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER '5u'- <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site V ' <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and regulation he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> m —FEE <br /> LESS v <br /> PRORATION <br /> PLUS <br /> PENALTY , <br /> OTHER <br /> OTHER ,. <br /> Received by Date - ` ` 1 i/ ` 7 - <br /> Receipt No Permit No: Issuance Date Mailed were 4 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,0'95201 l <br />