Laserfiche WebLink
Applications Will Be Processed When Submitted Property,Completed.Be Sure To sign Tne Appimanon. <br /> APPLICATION <br /> (For Non-Transferable,Rerocable7'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business IO lhejurisdictional areaof the San J aquin Local Health District <br /> m Business Name (DBA)._ MO Donald' Septic & Backhoe , Address 4g�5 Hil'dreth Lane 1 <br /> �T. R. .McDonald Address Same <br /> Owneri '. ".�, .. _ .. ' .:� . . <br /> Firm Partners, Addresses and Telephone <br /> Numbers Emergency Telephone No. 4'57-402(7 <br /> Business Telephone-No. 1 67 <br /> 44 <br /> Contractor Licence No. - Owner - Dale _ <br /> Applicants Name (Print) T. R... McDonald - Title• .. ..-.. <br /> Please check Applicable Category (1-7) and Fill In the Required Information., .,,'.. _j, . .. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June'30,19= -- Disposal Sites - �- - <br /> Description(Make/Yr.,Color) ,. CAL. License Renewal No. . <br /> Serial No. CAL.License No. - <br /> Capacity Gal.,Welgbts&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 r.r <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name ,_ <1 R.S or R.C.E.No. - <br /> 7est Date/Time r r <br /> Test Location !y <br /> d. ❑ SANITATION PERMIT � <br /> Job-Address/Locati gn - <br /> Owner • d s' <br /> SEPTIC TANK ❑ ESSP OL .LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW. REPAIR ❑ OTHE <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June,30, 19 <br /> Type Construction l L _ Disposal Site ' <br /> No.of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name -_ <br /> Plant Location - No. Units Served .t <br /> _Plant Capacity - <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> 'SIZE: ❑ Less Than 1,000 Sq. Ft., .113 More Than 1,000 Sq. Ft. <br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this applica ion and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and r les reg o.s oj-t�htqkSan Joaquin Loci Health District. <br /> APPLICANTS SIGNATURE X <br /> 4.�.•a.f� - ta.f� I�I�OAAY' cc�.A�1:a:�. � <br /> FOR DEPARTMENT USE ONLY <br /> Fee.IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH j❑ January 1 a Recelved By January 31 ❑ July 1&Received Byl JUIy 31 <br /> REM <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE MIT <br /> DATE REMITTED AMOUNT <br /> FEE <br /> 44 ' - <br /> � <br /> LESS <br /> PRORATIONPLUS <br /> ' <br /> • PENALTY <br /> OTHER J r <br /> OTHER r s <br /> 3(o2- <br /> Received by Date Rau Pt No. Permit No, law nce De Wiled Delivered <br /> L COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA=LTON AVE.,P.O,cos 2MSTOCKTON.CA 0201— <br />