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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 3 <br /> 0 (� APPLICATION <br /> [ on-Transferable,Revocable,and SusP endable SEPTAGE <br /> k 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 /> U Business Name (DBA) Valley Mechanical, Inc. Address P.O. Box 5126 Stockton, Calif. 95205 <br /> i Owner San Joaquin County Address 222E Weber Room 691 Stockton, Calif. 95202 <br /> u Firm Partners, Addresses and Telephone Numbers P.O. Box 5126 Stockton, Calif. 95205 (209) 931-4031 <br /> 0. Business Telephone No. (209) 931-4031 Emergency Telephone No: (209) 931-4031 <br /> Contractor Licence No. 333319 <br /> L Applicants Name (Print) Jim Haley Title Estimator Date 8/16/82 <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking,A(rdress <br /> 2. ❑ PUMPER YARQ <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 1R.S.or R.G.E.No. <br /> Test Location Test Date/Time <br /> 4. ® SANITATION PERMIT i M <br /> Job Address/Location 7.5 miles South of Highway 120 on Airport RRuad " <br /> Owner San Joaquin County Address 222 E. Weber Room 691 Stockton Calif. 95202 <br /> ® SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD- ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPO)3- RY 13 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,'-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleanin `Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For.July 1,-J,4 30, 19 <br /> Operator Name Wher&Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July,1, --June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., N❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Prmount/Mo. <br /> Flomeovimerdrticenpedagents signature cwtifiesthefonnwing "lrerilfytha}fnfheperformanceofthe, cr!*fn R,h.chthispermitisissued,Ishallnotemployanyperson <br /> in such manner a�to,become subject to workman's compensation laws of 0!h,ol rt;; ' <br /> Contractor's hiring or sub-contracting signature certifies she following: "i certify that III the peliu:mastsv of.he work for which this permit is issued,I shall <br /> eplploypersons subject to workman's compensation laws of California.- <br /> 'I hereby certify that i e prepared t is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state taws a d rules a gui $ ; the an Joaquin Local Health District.' ' f <br /> APPLICANT'S SIGNATURE X "` <br /> FOR DEPARTMENT 41SE ONLY'• G-iLGsc l/l3 <br /> Fee Is Due:❑-ANNUALLY ❑ PER UNIT- n ❑?P4R,SITE' 4 EACH ❑ J.—art,1, Rpceived By January.11 ❑ July 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> • BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Z <br /> PENALTY <br /> OTHER OF <br /> OTHER <br /> Received by,- Date Receipt No. Permit No. 71ss;uancDat�e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.80x.2009 . STOCKTON,,CCA�95201 <br />