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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 /> r <br /> LIQUID WASTE <br /> Application 1 hereby made to carryon btamess in the jurisdictional area of the T�, oa u Lo I Health Distri t' <br /> OF Business Name (DBA) alley Mechanical Inc. Address T "� • Waterloo, &ockton + <br /> aOwner Geor e Fleck Address 606 S. Reid, Linden, GA <br /> Firm Partners, Addresses and Telephone Numbers 209/931-4031, Vernon Stirm, 3122 Polk Way, Stockton, CA <br /> E Business Telephone No. 20 1-40 1 Emergency Telephone No. —'—_ <br /> Contractor Licence No. #333319 <br /> LApplicants Name (Print) George Fleck Title President Date 10-30-79J <br /> Please check Applicable Category (1-7)and Fill in the Required Information (� r <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 Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> Y <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. 1 <br /> Test Location Test Date/Time <br /> 4. ® SANITATION PERMIT <br /> Job Address/Location 7393 E_ La <br /> Owner Mi kP Seol ye Address <br /> *AM SEPTIC TANK ❑ CESSPOOL LEACHING FIELD_ ❑ SEEPAGE PIT ❑ -PACKAGE-PLANT <br /> ❑ PERMANENT ❑TEMPORARY NEW ❑ REPAIR ❑ OTHER **1,900, gallon tank, <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 <br /> Operator Name Where Certified <br /> Plant Location µ . <br /> Plant Capacity I No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ° <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> . i <br /> r• ( <br /> I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ P7EXPLANATION <br /> NIT PER SITE. ❑ EACH ❑ January 1,&Received By January 31' ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> Ji- <br /> LESS At <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER \\� <br /> OTHER <br /> Received by Date }f Receipt No. Permit No- Issuance Date Mailed Delive d <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.-box 2009 $TO TON, A 9 1 - <br />