Laserfiche WebLink
Applications Will Be'Processed When Submitted Properly Completed. Be Sure}To_S__i_gn The.Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE j <br /> t LIQUID WASTE <br /> Application is hereb de to car on b sine s i he'urisdictional area of the San Joa uin ocal He Ith District <br /> H Business Name (DBA) McDonald Septic 'rank. ` e vice Address 4645 `} idreN Lane .[ <br /> QOwner T. R. McDonald Address <br /> 4645 Hildreth Lane <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931--0497 Emergency Telephone No. 957'" 4 7 <br /> Contractor Licence No. 308171 � <br /> ' <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> k 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 <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 /> I a. ❑ SANITATION PERMIT <br /> i Job Address/Location <br /> Owner Address f <br /> ❑ SEPTIC TANK ff CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> t ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> N Operator Name l 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 /> r <br /> r 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 regu04,pns of the San Joa uin Local Health District. <br /> r APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Recei_ved.By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> e AMOUNT <br /> L FEE fQS `7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> R <br /> tl OTHER <br /> ` OTHER <br /> 3� s l 1 AV-7-1 <br /> G.Z <br /> y Received by .Date tt11 Receipt No. ermil No. Issuance Date Mailedeliver d _ <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCK ON,C 95201 , '- <br />