Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r V J APPLICATION <br /> I (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business Name (DBA) McDonald Septic Tank Service Address 4645 Hildreth Lane <br /> a Owner T. R. McDonald Address same <br /> u Firm Partners, Addresses and Telephone Numbers 64 <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-4027 <br /> 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 <br /> 1. ❑ PUMPER_VEHICLE PERMIT REGISTRATION_ (FOR EACH VEHICLE) <br /> For July 1, June 30,`19 ` Disposal Sites�•- y <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 4 • % . <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST - --- - . - - <br /> . i <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location L Test Date/Time j <br /> 4. ❑ SANITATION PERMIT Q <br /> Job Address/Location �' �" Of All <br /> Owner Address C . <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 0SEEPAGE PIT El PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑`OTHER <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 r+h� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 """ + A <br /> Operator Name Where Certified <br /> Plant Location l <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ``x' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than�1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> t <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, aid <br /> rules and regulatio f the San Joaquin Local Health District. } Ir <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Iq PER SITE Cl EACH 1P Jan aft YS Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMI T $ <br /> BASE EXPLANATION DATE D REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE . �y,� <br /> LESS �( <br /> PRORATION Oy <br /> PLUS <br /> PENALTY 01 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Isstiance Dble Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCK ON,CA 95 1 <br />