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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUI6 WASTE <br /> l <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District_ <br /> F Business Name (DBA) Valley Mechanical Inc. AddressP•0. Box 5126 - 5 o `CA 95205 <br /> Geor e J. Fleck P.Q. Box 5126 ,- Stockton, CA 95205 <br /> z Owner g . Address _ t <br /> < - - - 209/931-4031 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ..2 0 9/9 3 1-4 0 3 1 Emergency Telephone No..2 - 1 <br /> Contractor Licence No. 333319 <br /> a Jim H a.l a Title Date - - <br /> Al <br /> Applicants Name(Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information „ Q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, -' - June 30, 19-- - Disposal Sites = <br /> Description(Make/Yr., Color) <br /> i <br /> Serial No. ; CAL. License No. CAL. License Renewal No. P <br /> 7 <br /> Capacity Gal., Weights A Measures No. ; <br /> Equipment Parking Address _ z <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 R.S. or R.C.E. No. <br /> Test Location ' . Test Date/Time <br /> 4. EY SANITATION PERMIT <br /> tJobAddress/Location 11550 . Harlan Rd. - Lathrop, CA 95330 <br /> Owner Bob Stenson Address 155 Montgomery St. - San Fra;,ncisco , <br /> ❑`SEPTIC TANK ❑ CESSPOOL x® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13PERMANENT ❑ TEMPORARY 11NEW X® REPAIR ❑ OTHER. <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment 5tora6e_/:C leaning Location(s) Z-1 <br /> 6. ❑ PACKAGE TREATMENT PLANT or July 1,,,June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7.V ❑ LAUNDRY~For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Mork Than 1,000 Sq. Ft. <br /> ❑.DRY CLEANING,Chemicals Used/Amount/MO. <br /> _ I <br /> i 11RILp6+,gtlt3l�11irtii�»sedngent'ssigneturecertifiesthelortowing:'1certifythatintheperformameoftheworkforwhichthispermitisissued,Istraitnot employ arty person <br /> - in such manner as to become.subject to tirnrk,.�an':r,orapensation laws^-f Calitornia." <br /> e Can!ractor's hirirw or st,f>+,)rtractsrsrE signRtum. the to"Eowi�rg: "i certify twat-n the performance of the work for which this permit is issued,I shall <br /> er p!oy Persons subject to vloifi,rlan's comperlsalioll fjLn of Calilor lo."_ <br /> hereby certify that I have p ed this appl' ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an Lie and regul i s of Sa Joaquin Local Health District. '. C <br /> APPLICANT'S SIGNATURE X ' <br /> f FOR DEPARTMENT USE ONLY <br /> Fee IS'DUe: —1ANNUALLY ❑ PER UNIT- x❑ PER SITE` 13 EAC ElJanuary i &Received By January 31 ❑ Jusy i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE r DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS 1 3 <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> _OTHER <br /> Received by Hate Receipt No: Permit No. Iss anc to Mailed Delivered <br /> a. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE§ 1601 E.H N AVE.,P.O.Box 2009 STOCKTON,CA 95201 t <br />