Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. tse Sure Io Sign the Application. <br /> APPLICATION J <br /> �or Non-Transferable, Revocable,and Suspend'*I SEPTAGE <br /> c. 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 /> Business Name (DBA) McDonald Septic Tank Service Address 4649; HildrPth lane <br /> eOwner T. R. McDonald Address Same <br /> Firm Partners, Addresses and Telephone Numbers ^�1 <br /> Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 Q <br /> Contractor Licence No. 308171 1 <br /> a 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 /> I.Serial No. CAL. License No. CAL.Llccnse 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 <br /> No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. C <br /> Test Location Test Date/Time <br /> `4. ❑ SANITATION PERMIT r <br /> Job Address/Location <br /> Owner Add ss <br /> 4 ❑ PAC❑ CESSPOO <br /> J SEPTIC TANK L LEACHING V ❑ SEEPAGE PIT <br /> KAGE PLANT <br /> �' PERMANENT ❑ TEMPORARY IN NEW "'Y ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> r 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 /> e <br /> r <br /> Plant Capacity No. Units Served � <br /> 7.. ❑ LAUNDRY For July 1, -June 30, 19 <br /> ShE: ❑ 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, and ul d regulations of I an Joaquin Local H th District.- <br /> r APPLICANT'S SIGNATURE X � • ri•"�A'AD <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January/&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 4_5 clklkl 4 Lfs <br /> � L <br /> LESS e <br /> PRORATION Vrr`*� <br /> 4 <br /> PLUS <br /> PENALTY <br /> OTHER J2 <br /> r <br /> ` OTHER <br /> Received by Date Receipt No. Permit No. I Issuartce Date Mailed Delivered / <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA%201.— <br /> .. <br />