Laserfiche WebLink
Applications Will Be Processed When;submitted Properly Completed. Be Sure To Sign The Application. i <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ! <br /> Application is hereby a e t car n b nes e jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) McDona�c Sep--- `�lan�m Service Address 4645 Hildreth Lane <br /> Z owner <br /> T. R. McDonald Address same <br /> It <br /> J Firm Partners, Addresses and Telephone Numbers 957-4027 <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. <br /> J Contractor Licence No. 308171 <br /> Applicants Name (Print) T. R. McDonald Title Owner Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information Q} <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION�(FOR EACH VEHICLE) <br /> For July 1 t ' '° }June 30, 19 •. 'Disp sal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Rencwal 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 """'"""-""�`" r <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Test Location Test Date/Time <br /> .� <br /> 4. 13 SANITATION PERMIT <br /> Job Address/Local n i <br /> Owner Address <br /> ❑ SEPTIC TAN CESSPOOL ❑LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ii <br /> ❑ PERMANENT ❑ TEMPORARY ❑y NEW L�ftEPAIR El OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br />` Type Construction Disposal Site filtf <br /> No. of Units +5 - Equipment_Storage/Cleaning_Location(s) -- <br /> 6. 13 PACKAGE TREATMENT PLANT For July 1, June 30, 19' i Q <br /> Operator Name Where Certified ,�.. <br />' Plant Location It <br /> Plant Capacity ' No. Units Served <br /> 7. ❑ LAUNDRY For July , ,1 -June 30 19 1 <br />, 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ 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 regulafions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUE X <br /> R <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 /> i REMIT <br /> BASE FXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> } DATE DATE REMITTED L/ AMOUNT <br /> FEE a y 'E <br /> 1 �L -+.►may <br /> LESS •• X1 �� e• / S <br /> PRORATION, - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 06 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOGKTON,CA 95201 <br />