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Applications Will Be Processed When Submitted Properlycompiemo. <br /> APPLICATION <br /> 2 i (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area the San 4634AaE�n WaterlooLocal Health 4Rdict 5 <br /> Address s <br /> F Business Name (bBA) 606 S. Reid Ave. <br /> a owner Geo r e J. Fleck Address <br /> N/A <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. <br /> a 3319 T1arPmhc?1^ 15,_.�9� <br /> Contractor Licence No. 33Title PreSiderit Date <br /> LApplicanks Name (Print) Geor e J. Fleck <br /> Please check Applicable Category (1-7) and Fill in the Required Information OBJ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> q. 5 SANITATION PERMIT <br /> Job Address/Location— 1045$ S.—a' <br /> 10 <br /> Bill Beard Address 45$ S. Priest Rd. French Cam CA <br /> Owner 13 PACKAGE PLANT <br /> SEPTIC TANK 11 CESSPOOL EK LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT 1:1 TEMPORARY ❑ NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 a <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name (f' <br /> Plant Location <br /> No. Units Served' <br /> Plant Capacity <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 /> I hereby certify hat have prepared this application and that the work will be done in accordance wit Joaquin County <br /> ordinances, state w and rules a d gu <br /> he n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> George eck President � <br /> FOR DEPARTMENT USE ONLY <br /> ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J uary ceive By January 31 ❑ dusy i &ReceivedREMIT 31 <br /> Fee Is Due: ANN <br /> BILLING REMITTA $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE ATE REMIT D AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s <br /> Receipt No. Permit No. Issuance Date Mailed De vered <br /> Received by Date 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />