Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: I <br /> APPLICATION0 <br /> (For Non-Transferable, Revocable,and Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT SE?TAGS { <br /> LIQUID WASTE } -A <br /> Application is herebyade to carry on businPcc in the jurisdictional area of the San J aquin Local Health District 6 <br /> rBusiness Name (DSA) MC Ed Septic Tank -.Service Address 46+5 Hildreth Lane <br /> ? Owner T.R. McDonald Address Same <br /> Q <br /> Firm Partners, Addresses and Telep"lone Numbers <br /> a931-0497 Telephone No. 93L—Q497 Emergency Telephone No. 957-4027 <br /> Contractor Licence No. •R. McDonald Owner <br /> Applicants Name (Print) _ Title 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 /> Serial No. CAL. License No. CAL. Licc;ise Renewal No. 4. <br /> Capacity Gal., Weights & Measures No. , <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 V <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time` <br /> 4. ❑ SANITATION PERMIT ry/ <br /> Job Address/L tion 66 <br /> r <br /> Owner � 4A dd re <br /> ❑ SEPTIC TANK ❑ CE55 OOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> —❑ PERMANENT ❑ TEMPORARY 10 NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <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 regulations o San Joaquin Local H I <br /> th District. <br /> APPLICANT'S SIGNATURE X <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 Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING E!ATE <br /> TANCE $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEE -�� <br /> LESS <br />�E PRORATiON <br /> PLUS <br /> PENALTY <br /> OTHER to <br /> OTHER <br /> '7q— q 1 ?9 <br /> Received by Date. Receipt No. Permit No. Issuance Date Maired Delivered <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVEC.,P.O.Bo:2009 STOCKTON,C _ <br />