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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Suspendable o <br /> „�\ ( on-Transferable,Revocable,and SEPTAGE <br /> ENVIRQNMENTAL 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) Valles Mechanical Inc Address P.O. Box 5126 Stockton, Calif. 95205 <br /> z Owner San Joaquin County Address <br /> 222E Weber Room 691 Stockton, Calif. 95202 <br /> Firm Partners, Addresses and Telephone Numbers P.O. Box 5126 Stockton Calif. 95205 (209) 931-4031 <br /> a09)Telephone No. (209) 931-4031 Emergency Telephone No. (209) 931-4031 <br /> Contractor Licence No. 333319 <br /> Applicants Name (Print) Jim Haley Title Estimator Date AI1R/82 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) �V <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights&Reasures No.. �} <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD -- - 104 <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 Frp.E. No. <br /> Test Location Test Date/Time <br /> 4. ESANITATION PERMIT <br /> Job Address/Location 7.5 miles south of Highway, 120 on {}irport Road Z <br /> Owner San Joaquin County Address 222 E Wober Room 691 Stockton, California 95202 <br /> ® SEPTIC TANK ❑ CESSPOOL ©-LEAGCRIN6*ELD •❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> + <br /> Site <br /> .Type Construction '. Disposal -" <br /> No. of Units ' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE:rREATM. ENT PLANT For July 1, -June 30, 19 <br /> r f Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Servecl <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. x <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> HOmeowner orlicensed agerl%S'.gna*arerlaTtlt". thtnfoin.•r"nr I ,..'ify h-_'...:.the,.Frfor;ta^CC ofthpwx.kf,;,,,:h;T! this perm it isissued;n atlnot employanypersaii <br /> is such manner as to become suNer.1 to <br /> Contractor's hiring nr suh rc..ra..{•neb I ceriity that in the."per errnancc cl t..e work for which this permit is istued,1 shall <br /> employ persons subject to workma+i s coxpensala.°as m <br /> I hereby certify that l hav repared this pplication and that the.work will be done in accordance with San Joaquin County <br /> ordinances, state Jaws, a` ides a' atio f.thelSao Joequin,Local Health.Distr'rct. . <br /> ;, . <br /> APPLICANT'S SIGNATURE X 1 <br /> 077z9_5 Z_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s pue:'O. , A(,6V ❑"PER'VNrr ❑ PER SITE Q•EACH ❑ January_t &Received By January 31 [3 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION MLI G, REMITTANCE $ AMOUNT DUE CHECKED <br /> ` 6A :DATE REMITTED AMOUNT <br /> FEE <br /> LESS �0 �- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssuan ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />