Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. liesure 1o sign Ine.,NNr,.a ..,,• <br /> APPLICATION <br /> (For Non-Transferable, Revocable,"nd Suspendable) SEPTAGE <br /> i� <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 /> rn Business Name (DBA) McDoi2a.ld .ept!_Q &. Backhoe Address 1+6 5 'HildEeth Lane` <br /> McDonald _Address Satre <br /> aOwner. � ;'n - - <br /> J Firm Partners, Addresses and Telephone Numbers 957=-•x.027 <br /> a ,Emergency Telephone No. <br /> M Business.Telephone No. - - .t � <br /> -J Contractor Licence No - OWrieT' ' <br /> �APpcMants Name (Print) MCDoriald 1 Title, f-: Date <br /> Please check Applicable Category(11-7) and Fill in the Required Information .� pt,.t'::,. N , t3 rr; ;fzyz <br /> 1. ❑ <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR-EACH VEHICLE) <br /> For July 1, June 30, 19= =' T- Disposal Sites <br /> r .. <br /> Description(Make/Yr., Color) fi. ; <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> �.. <br /> Capacity Gal., Weights & Measures No. r 4­�v t. <br /> Equipment Parking Address - I� } 7. <br /> i 2. ❑ PUMPER YARD <br /> For July'1, June 30, 19 <br /> No. of Vehicles Stored <br /> s No. of Chemical Toilets Stored IK <br /> 3. 11 PERCOLATIONTEST <br /> R.S. or R.C.E. Name R.S.or,R.C.E. No. <br /> 1 Test Location Test-Date/Time t t <br /> - <br /> 4. El SANITATION PERMtT 1 <br /> Job Addres /Location P4 x W .1 <br /> Owner <br /> ._..i �j _ Address <br /> —,� AGE PLANT?, <br /> f <br /> ❑3 <br /> ❑ SEPTIC TANK El CESSPOOL ❑ LEACHING FIELD ❑ SEEPrAGE PIT PACK� , <br /> 13 PERMANENT ❑ TEMPORARY 13 NEW ❑ REPAIR , OTHER U' <br /> 5. -1 CHEMICAL TOILETS For July 1, -June 30, 19 ; t .p r <br /> Type Construction �I - - Disposal-Site <br /> Yp �`c . ) <br /> No. of Units III Equipment Storage/Cleaning Location(,) <br /> 6. ❑ PACKAGE TREATMENT PLANT For JUly 1, -June 30,'19 <br /> Operator �I I Where Certified <br /> O Name <br /> P !i <br /> Plani Location _ } <br /> ,No. Served <br /> Plant Capacity t� � <br /> 7. 11 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. F ` <br /> hereby certify that 1 have prepared this application and that the worK will'be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru n latio the San Joaquin al Health District. <br /> APPLICANT'S SIGNATURE X _ <br /> S - FOR DEPARTMENT USE ONLY a <br /> r Fee Is Due. ❑ ANNUALLY.I� ❑ PER UNIT- ❑ PER SITE _ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &jReceived By Juiy 3t <br /> Ili REMIT <br /> BASE BILLING REMITTANCE., $ AMOUNT DUE CHECKED <br /> EXPLANATION REMITTED – w°`fes <br /> . _ -}� DATE .DATE - AMOUNT <br /> i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ,`Lp <br /> OTHER <br /> OTHER <br /> Received by Rate Receipt No. K Permit No. Issuance Date Mailed Delivered <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL c'OPIEs TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1661 E.HAZELTON AVE.,P.O.Box 2009 <br /> Ib . <br />