Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ �. APPLICATION' <br /> _Ax (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT n Z EPT-AGE=_, <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District _ <br /> OF Business Name`(DBA) McDonald Septic Tank Service Address 4645 Hildreth Lane <br /> 5 Owner T . R. -McDonald Address 4645 Hildreth Lane <br /> I , <br /> J Firm Partners, Addresses and Telephone Numbers # <br /> IL <br /> Business Telephone No. Emergency Telephone No. 957-4027 . <br /> Contractor Licence No. 309171 <br /> L Applicants Name (Print)—_ T R McDonald 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)_ <br /> Serial No. CAL. License No. CAL. Licc-ise Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address u <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored S' <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 a` <br /> 4. SANITATION PERMIT y <br /> Job Address/Locati F ; <br /> caner Address <br /> .i t <br /> SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW 11 REPAIR ❑ OTHER ; <br /> 5. 1-1CHEMICALTOILETS. For July 1, -Ju a 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <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. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> z <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, and rules and regulations he San Joaquin Local ealth District. », <br /> APPLICANT'S SIGNATURE X - <br /> S <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 /> - <br /> BREMIT <br /> ILLING REMITTANCE $ <br /> BASE - EXPLANATION DATE DATE REMITTED• AMOUNT DUE CHECKED <br /> -w.— AMOUNT „ <br /> v <br /> FEE <br /> LESS /�- <br /> PRORATION "✓— <br /> PUL <br /> ALTY LUS <br /> PEN4 <br /> OTHER K <br /> f <br /> a <br /> OTHER_ <br /> _Ai <br /> Received by - Date Receipt No. - Permit N6. Issuance Date Mailed Delivered f <br /> APPLICANT—RETURN ALL COPIES M ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Si5x 2009 STOCKTON,CA 95201 4 <br />