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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I <br /> APPLICATION <br /> ;- (For Non-Transferable, Revocable, and Suspendable) <br /> F ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <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) Valle y Mechanical , Inc . Address E . Waterloo Rd . Stockton <br /> aOwner George J. Fleck Address 606 S. Reid Ave. <br /> L) Firm Partners, Addresses and Telephone Numbers Same As Above � <br /> aBusiness Telephone No. 931.4031 Emergency Telephone No. 462-2905 <br /> Contractor Licence No. 333319 <br /> Applicants Name (Print) Jim Haley Title Estimator Date 215182 <br /> _ <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. Liccrse Renewal No. ' a <br /> Capacity ',.+ Gal., Weights & Measures No, <br /> Equipment Parking Address <br /> 2. 13 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. ❑ SANITATION PERMIT «. <br /> Job Address/Location 36 W. Matthews Rd. Stockton CA. !} <br /> Owner Silva Properties Address 2119 West Alpine Stockton 95204 <br /> El SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW It ❑ REPAIR ❑ OTHER UJI <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 6a <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 r <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 /> - 4 <br /> 3 <br /> 1 hereby certify that 1 ha repared this ap li ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d r les and regula o s of th . an aquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> ria O r <br /> d <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ July 1 &Received By July 31 d <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S / <br /> LESS —( i <br /> PRORATION <br /> PLUS <br /> PENALTY -• <br /> OTHER <br /> i <br /> OTHER <br /> ,a <br /> Received by Date Receipt No. Permit No. I Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 1 ! <br />