Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppllcailon. <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'urisdictionalarea of-the Sa Joa uin focal�+ 4tDi strlacnE. i <br /> Business Name (DBA) McDonald Septic & Bac hoev ' Addressb.4 L <br /> - <br /> T. R.-McDonald Address <br /> a Owner Same <br /> u Firm Partners, Add resses_rand,Telephone Numbers _ <br /> aBusiness Telephone No :' 931 L"049rr, i ( 'A >> Emergency Telephone No. <br /> Contractor Licence No. 133 7: <br /> a Owner Date <br /> 'T. R. McDonald , .. >, ;: .Title - - <br /> L Applicants Name (Print) <br /> J <br /> Please check Applicable Category(1-7)and Fiil in the Required Information 1- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 =Disposal Sites <br /> Description(Make/Yr.,Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. �_ � 4_.f <br /> Capacity" t N Gal.,Weights &Measures No. z�, . <br /> Equipment Parking Address • v <br /> 2. ❑ PUMPER YARD <br /> For July 1,J Ju�he%30, 19 t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> .3. ❑ PERCOLATION TESTI. <br /> R.S. or R.C.E. Name R.S. or R.C.E.NO', � <br /> 4 - <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location•.- A.' <br /> Owner Address <br /> ❑ PACKAGE PLANT <br /> i' C&SEPTIC TANK HI <br /> ❑ CESSPOOL, LEA FIELD SEEPAGE PIT I ' <br /> 11PERMANENT ❑ TEMPORARY I NEW [ar- FIEPAI:R, 13 OTHER til <br /> 5. 11CHEMICAL TOILETS-For July 1, June 30, 19 • y j <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 <br /> Where Certified t ' <br /> Operator Name <br /> Plant Location .NoUnits <br /> Served. b <br /> Plant Capacity j <br /> 7. ❑ LAUNDRY for July 1;-June 30, 19 '�-w - . . " f <br /> ❑ Less Than 1,000 S Ft '❑ More Than 1",000 Sq. Ft.C <br /> SIZE: q`- .• '- <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 /> in Local Health District^ ' <br /> ordinances, state laws, and;rules and re tions of the San J q.,uF 4 - <br /> APPLICANT'S SIG +ATURE X J. <br /> FOR DEPARTMENT USE`ONLYd BY - <br /> _ Fee 1s Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1f8 ReceiveR MITUIy 31 <br /> T # BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> BASEEXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEE 1� S <br /> LESS { <br /> PRORATION N <br /> PLUS <br /> f i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> F r- Delivered <br /> *" pate S _ Receipt No. Permit No. <br /> Y uance ailed ,.•_;� <br /> Received by - - <br /> 1601 E.'HAZELTON AVE.,P.O:-Box 2009 ",'STOCKTON,CA 95201 <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - <br />