Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SP7AGE <br /> LIQUID WASTE <br /> Application is hereby!' ade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) McDonal d Septic Tank, Service Address 4645 �lldre a <br /> z Owner- <br />:0 <br /> T. R• McDonald Address sada � <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No.- 931-04-P-7 Emergency Telephone No. 9 �— <br /> Contractor Licence No. 3081711 <br /> Applicants Norrie (Print) T R 11c11oa ld-' Title OTe11Ter Date <br /> Please check Applicable Category (11-7)-end Fill In the Required information <br /> 1. ❑ PUMPER VEHICLE-PERMIT A'EGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19"k �� - Disposal Sites _ <br /> Description(Make/Yr., Color) <br /> Serial No.No. CAL. Lieense'No. CAL. Liccnse Renswal No. 0 <br /> Capacity �.�Gal., Weights &Measures No. <br /> Equipment Parking Address iiI <br /> 2. ❑ PUMPER YARD I� <br /> For'July 1, June 30, 19 <br /> No. of Vehicles Stored �p <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I�I L "ii* `R.S:'or RC:E. No. <br /> �+ <br /> I� I <br /> R.S. or R.C.E. Name ' <br /> If <br /> Test Location Test Date/Time X' <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ` <br /> Owner Add re s 4 _ <br /> SEPTIC TANK ❑ CESSPOOL' - 9LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> U PERMANENT ❑ TEMPORARY NEW-. REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For JuyIly 1, -June 3011 1' <br /> f <br /> Type Construction dLL isposal Site <br /> No. of Units 'Ir Equipment Stprage/Cleaning Location(s) .. <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 { , <br /> Where Certified 1 t <br /> Operator Name pp I <br /> Plant Location iQ f - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ,. <br /> SIZE: ❑ Less Than 1,000 Sq. Filt ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. # <br /> I ♦ f f { <br /> A <br /> I hereby certify that I have prepared this appli ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a`d ru nd re lati of)the San Jo uin ocal Health District. <br /> APPLICANT'S SIGNATURE X I <br /> II� FOR DEPARTMENT USE ONLY - - <br /> Fee Is-Due: ❑ ANNUALLY :❑ PER UNIT 1:3PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE I� EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> [ DATE t DATE REMITTED AMOUNT <br /> r t <br /> FEE -� `l �,� <br /> I <br /> 48 <br /> LESS <br /> PRORATION II� <br /> PLUS ' r <br /> PENALTY ;III <br /> OTHER :I� <br /> OTHER <br /> I <br /> t--Fo & <br /> Received by Date lit: Receipt No. Permit Na Issuance Date Mailed Delivered <br /> 1601 E.HA2ELTON-AVE.,P.O.Bar 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMrr/SERVICES <br /> i <br />