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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> `\ ( on-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL <br /> r, N HEALTH PERMIT <br /> A LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) Val 1Py Mechgni r,.Rl, Inc Address p n Rnx 5126 Stockton,,Calif. 95205 <br /> a Owner San Joaquin o n y Address 222 E, 'Weber" Room 691 Stockton, Calif. 95202 <br /> Firm Partners, Addresses and Telephone Numbers P.O. Box 5126 Stockton, Calif. 95205 (209) 931-4031 <br /> (209) 931-4031 Emergency Telephone No. (209) 931-4031 <br /> a enc Business Telephone No. 9 Y P <br /> Contractor Licence No. 333319 <br /> aEstimator Date 8/18/82 <br /> L Applicants Name (Print) Jim Haley Title <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) p � <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.,4ddress <br /> 2. ❑ PUMPER YARD <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 I R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. © SANITATION PERMIT <br /> Job Address/Location 7.5 miles south of Highway 120*I n rAirpbxt Roza <br /> Owner San Joaquin County Address 222E Weber Room 691 Stockton, California 95202 <br /> ® SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD SEEP i'sPIT ' ❑ PACKAGE PLANT <br /> ❑ PERMANPNT ❑ TEMPORARY ® NEW ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type ConstructjonDisposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,:-June 30, 19 <br /> Operator Name Where 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., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed agent's signature certifies the following:`Icertifyt`ifIr-he nrr`orma BerftheAlcr! :or,dh`�hthispermitisissue("s!1.',!Inotemn <br /> In such manner as to become subject to workman's compensation lava's of Califrlrr; <br /> Contractor's hiring or sub-contracting signature: certifies t6 foliowing: i.l.t t{Cri ,:.t a.,: he lvork is issec" <br /> employ persons subject to workman's compensation laws of California." for which this permit <br /> I hereby certify that I v prepared th' application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law a' rules i s,of the San Joaquin Local yealth District <br /> APPLICANT'S SIGNATURE X ' <br /> l� <br /> FOR DEPARTMENT UA ONLY (!"/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE" <br /> LESS , <br /> PRORATION "D <br /> PLUS <br /> PENALTY /1Oro <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Perm o. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bex 2009 STOCKTON,CA 95,2.011 <br />