Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District • <br /> N Business Name (DBA) Me TlC)naI d SP t,J n Rr Rn n k h nP Address 4645 Ri ]9rL-th T ;:i <br /> z Owner T. R. McDonald Address Same <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 957-1027 <br /> Contractor Licence No. 133679 <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 /> Descriptlon(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 <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 Oate/Tlme <br /> 4. ❑ SANITATION PERMIT i <br /> Job Addressl�cation <br /> Owner Address Or I Lr <br /> IWISEPTIC AU ❑ C SPOOL ❑ LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW EPAIR ❑ 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 e <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 CLE=ANING,Chemicals Used/Amount/Mo. <br /> T" i <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordancewit In Joaqu County <br /> ordinances,state laws,a rule regulations San Joaquin Local Health District. <br /> ,.�. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee It.Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 4 s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1�9 -7 y <br /> Received by Date Receipt No. Permit No. IssuancelDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 . <br />