Laserfiche WebLink
{Applications Will Be processed When Sub�mitP <br /> PLICAT,ON <br /> (For Non-Transterable, Revocable,and Suspendable) SEPTAGE / s <br /> SNVIRONMENT HEALTH <br /> PERMIT <br /> LIQUID WASTE <br /> lication ishereby made to carry on business in the jurisdictional area osthe San Joaquin Local Heath District <br /> APP . <br /> N Business Name (DBA) <br /> Address r/ r - <br /> a Owner <br /> 2 Firm Partners, Addresses and Teleph e Numbers <br /> Emergency Telephone No. <br /> aBusiness Telephone No. Date <br /> Contractor Licence No. - �� Title t } _ <br /> v ) <br /> L applicants Name (Print) 'red Information <br /> Applicable Category (1-7)"and Fill In the Req <br /> Please check App .- <br /> 1 ❑ PUMPER VEHICLE PERMIT REGISTRATION (FODispoEaICSites <br /> VEHICLE) <br /> _�June 30, 19 <br /> For July 11 <br /> CAL. License Renewal No. <br /> Description(Make/Yr,, Color) CAL. License No• <br /> Serial No. Gal..Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> IF <br /> June 30, i9 ? <br /> For July 1, �- '1 <br /> i r t`. i-, <br /> No. of Vehicle Stored <br /> No. of Chemical Toilets Store ( - 4 <br /> 3, ❑ PERC�LATION TEtT <br /> f �- Test Date/Time <br /> R.S.or R.GE.�Name � <br /> Test Location' or <br /> 4, ❑ SANITATION PERMIT <br /> G 1"r r <br /> I Job Ad anion ` r Address j, -'� PXCKAGE PLANT i <br /> ownACHING FIELD ❑ SEEPAGE-'. <br /> SEPTIC TANK ❑ CESSPOO -- ❑ REPAIR ❑ OTHER y <br /> ❑ pERMAIVEidT ❑ TEMPORARY��,,,DNEVsI 1 <br /> P" <br /> t W i,-.June,30; 19 <br /> 5, 1:1 HE TOILET& For July. Disposal Site <br /> Type Construction Equipment Storage/Gleaning Location(s) � <br /> No. of Units _ : -- -a� T'- �" V <br /> y _ Where.Certilied — <br /> g• ❑•PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -` <br /> Plant Location § No. Units Served <br /> Plant Capacity <br /> jv June 30, 19 �-- <br /> 7. ❑ LAUNDRY t For Jul'.1,- ❑ More Than 1,000 Sq. Ft. <br /> ❑ Less Tliari 1,000 sq. Ft•, _---- rr <br /> SIZE: <br /> k <br /> C1 DRY CLEANING. Chemicals lysed1Amount/lulo. <br /> ft <br /> Y S.,f1 €€ ! t r <br /> ) ar,�d this`app.icatYior'i a�td'""that the work will be done in accordance withSanJoaquin County <br /> l 1 hereby certify that f have prep <br /> ordinances, state laws, and rules an., regirla ns of t alJ� �tn Local-Haaith Dis#r•ictnw <br /> l i r + y - <br /> I <br /> 1 APPLICANT'S SIGI lAT{z(RE X F ' <br /> � I � i s � <br /> i i ..r n� <br /> p FdR DEPAi 3ME�T:LISE`ONLY ye <br /> e Jul 31 <br /> - Jul 1 &Received By Y <br /> ❑ PER SIZE EA <br /> 1� January 1 S Received BY}January 3___A� � REMIT <br /> kk ❑ PER UNI7i ! r CHECKED <br /> Fee is Due: 0 AN LY l F l REM,ITTA CE $ AMOUNT UE AMOUNT <br /> e <br /> BIL NG ,rti RIEW-17 "'``"".� <br /> ,i BASF XP LANATION .., DA`1` <br /> _ ''--... <br /> s_ Is <br /> FEE <br /> LESS <br /> PRORATION " <br /> PLUSs — r t w4YC t Ji <br /> PENALTY <br /> OTHER <br /> OTHERS � � s � , <br /> J I sua(nOJce ate I Mailed Delivered <br /> - <br /> DReceipt No. <br /> Permit No 'aoa 2009 "STOCKTON,CA 95201 <br /> Received by <br /> ate IES 70: ENVIRONMENTAL <br /> APPLICANT—RETURN ALL COPHEALTH PERMITlSEFiVICES yg01 E.HA2ELTON AVE.,P.O. <br />