Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> I E-NVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> i ,F Business Name (DBA) McDonald Septic Tank Service. Address 4645 Hildreth Lane <br /> aOwner T. R. McDonald Address Stockton,s--Ca'. 95212 <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. 308171 <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 /> - <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL.License No. CAL. Liccnse Renewal No. <br /> I Capacity Gal„Weights & Mi asures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD { <br /> For July 1, . June 30, 19 I <br /> No. of Vehicles Stored <br /> f No. of Chemical Toilets Stored <br /> ij 3. ❑ PERCOLATION TEST <br /> If R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT f r, // <br /> Job Address/Location r� '— <br /> I Owner Address 6 <br /> I ❑ SEPTIC TANK ❑ CESSPOOLLEACHING FIELD' ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW _y REPAIR V OTHER.5U -L <br /> t \� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site F <br /> No. of Units _ Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name " Where Certified <br /> Plant Location <br /> 14 <br /> Plant Capacity No.Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 d <br /> SIZE: ❑ 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 rules and regulation f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> D <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 /> BASE ^", EXPLANATION BILLING REMITTANCE AMOUNT DUE CHEGKE <br /> DATE DATE REMITTED AMC N <br /> FEE <br /> LESS ' r, <br /> PRORATION 4. <br /> zPLLJ Y <br /> PENALTY !" <br /> OTHER <br /> OTHER <br /> FF Rec6ved by Date. Receipt No -Permit No. Issuance Mailed Delivered IT <br /> 4 - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br /> t . <br />