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Applications Will Be Processed When Submitted Properly Completed. Be SureTO sign Inemppeovauun a <br /> APPLICATIONS } <br /> (For Non-Tran"gterable, Revocable, and Suspendable) SEPTAGE f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the 0.Joaquin Local <br /> eStoGkton 95205 <br /> y Business Name (DBA) VALLEY MECHANICAL INC. Address— I <br /> z Owner—Geo1 a J. Fleck Address 606 S. Reid Linden <br /> Firm Partners, Addresses T�^_�^elephone N mbe <br /> a Business Telephone No. 1—SFO 1 Emergency Telephone No. <br /> a <br /> Contractor Licence No. 4-10-81 <br /> a Geer J. Fleck Title PreSident Date <br /> LApplicants Name (Print) <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 I <br /> M <br /> Description(Make/Yr., Color) <br /> Serial Na. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address = <br /> 2. ❑ PUMPER YARD r <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. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. 1E) SANITATION PER ( Z �V <br /> Job Owner <br /> HafflsoA• Fox 57 E. Harder, Stockton 9520 <br /> Owner 1 Address d <br /> ® SEPTIC TANK ❑ CESSPOOL CYC LEACHING FIELD � SEEPAGE PIT 1:1PACKAGE PLA <br /> ® PERMANENT 11 TEMPORARY NEW ❑ REPAIR 11 OTHER gal tank 6 f <br /> 5. 13CHEMICAL TOILETS For July 1, -June 30, 19 170.' leach line <br /> �. <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) t <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> t Plant Capacity No. Units Served <br /> It 7. ❑ LAUNDRY For July 1, -June 30, 19 y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. , <br /> r <br /> I hereby certify at have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state and rules a re do of th San Joaquin Local Health District, . <br /> APPLICANT'S_SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [].July 1 &Received By July 31 <br /> RE <br /> RASE EXPLANATION BILLING '.REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �~ Q <br /> • LESS <br /> i PRORATION <br /> PLUS <br /> PENALTY _ ✓`� - - <br /> OTHER <br /> OTHER . .. `• - - r <br /> Date Receipt N. Permit N. <br /> I suanc ate Mailed Delivered <br /> Received by t <br /> 1601 E.HAZELTON AVE STOCKTON,CA 95201 <br /> F APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERV <br />