Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> l APPLICATION I <br /> -' (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE f <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) McDonald q:ti C Tank SPrvi CP Address4645 Hi l dreth Lance <br /> aOwner T_ R _ McT)nnn 1 d Address q in <br /> J Firm Partners, Addresses and Telephone Numbers + <br /> aBusiness Telephone No. -931.-0497 Emergency Telephone No. i <br /> Contractor Licence No. 308171 ? <br /> Applicants Name (Print) T Pte. . MCDQuald 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, June 30, 19 _ A Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. t CAL. License No. CAL. License Renewal No. y <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD !} q <br /> `For July 1, - - June 30, 19 <br /> No. of Vehicles Stored 1 No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <br /> R.S. or R.C.E, Name t R.S. or R.C.E.'No. <br /> Test Location ' ' Test Date/Time. <br /> 4. ❑ SANITATION PERMIT ( #w W <br /> Job Address/Locat' n v � <br /> H <br /> Owner Address ) <br /> ❑ SEPTIC TANK ❑ CESSPOOL y❑ LE CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT �I <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW` �' REPAIR ❑ OTHER OOI <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 h <br /> Type Construction Disposal Site <br /> d <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 O <br /> Plant Capacity No. Units Served ~� <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> 1 hereby certify that I have prepared this applicat' and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a r nd r ulatio f th San Joaquin L cal Ith District. <br /> APPLICANT'S SIGNATURE X �"1✓L <br /> i� <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE Cd\ `tea. t <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> r <br /> OTHER <br /> h <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Maiied Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.'Bov 2009 STOCKTON,CA 95201 <br />