Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure Sign The Application. T <br /> e APPLICATION <br /> " (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the Sa u�'�1�pgal He It}}District <br /> Business Name (DBA) McDonald Se tic Tank Service Address <br /> F1i 1 Grath Lane <br /> I.- <br /> Owner d_d Address $dm@ <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. 957--4027 <br /> J Contractor Licence No. ., <br /> �Applicants Name (Print) Title Owner <br /> Please check Applicable Category (1-7)and Fill in the Required Information Date <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION'(FOR EACH VEHICLE) <br /> For July1, �e <br /> P .�.* 30, 1-~'k .4 � ' Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. Y <br /> Capacity Gal., Weights & Measures No. +� <br /> Equipment Parking Address tt< 1'Ql i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ <br /> t .w � <br /> No. of Vehicles Stored t <br /> No. of Chemical Toilets Stored I <br /> 3. C1 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. rdT !� ` <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT `� r <br /> Job Address/Location <br /> Qwner " Address <br /> EtUEPTIC TANK...❑."CESSP OL—ALLEACHING.F.IELD SEEPAGE PIT..,.❑,P_ACKAGE_PLANT f f j <br /> PERMANENT ❑ TEMPORARY Ll 4EW ❑1 <br /> REPAIR ❑ OTHER �f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site tr., ti <br /> No. of.Units Equipment Storage/..Cleaning Locationr(s)%k 1 �, <br /> 6. ❑"PACKAGE TREATMENT PLANT For July 1, -June 30, <br /> Operator Name' ` <br /> Where Certified <br /> Plant Location{ <br /> Plant Capacity No, Units Served 1 <br /> 7. ❑ LAL' DRY For July 1, -June 30, 19 <br /> SIZE: ❑"Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ...t 1 <br /> i hereby certify that I have prepared this aapplication,and that the,work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules re latIons— th`San Joaquin Loc I Health District. Y. <br /> v I <br /> APPLICANT'S�SIGN�ATUREX <br /> FOR DEPARTMENT USE ONLY°+ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ DER SITE El EACH 0 ❑ �- <br /> January 1 &Received y JanPpry I ❑ Ju &Receiv d By July 31 <br /> BASE EXPLANATION BILLING REMITTAN Et REMIT <br /> DATE DATE ^REM AMOUNT DUE CHECKED <br /> r <br /> FEE 4s !_ r 4'f OUNT <br /> 4�( LOtr�- '" T <br /> LESS <br /> PRORATION f <br /> ■ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date <br /> Receipt No_ Permit No, issuance ate Mailed Delivered Y b <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C 95 1 <br />