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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> �—Appl icatiioin is hereby m ade.to carry on siness in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) alley Mechanical Inc. Address . P•0. Box 5126, Stockton 95205 <br /> z Owner George J. Fleck it Address " <br /> t , <br /> Z Firm Partners, Addresses and Telephone Numbers <br /> a .Telephone No. (20 931-4031 Emergency Telephone No. Same <br /> Contractor Licence No. 333319 <br /> Applicants Name (Print) George J. Fleck Title President Date 6-3-8o <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. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD h <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> f <br /> 3. ❑ PERCOLATION TEST J <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ID SANITATION PERMIT 111 <br /> Job Address/ cation West Vane Frontage Rd. & Hammen Lane_ s <br /> Owner ; oak,�en'Golfland Address 8 50 N West Lane, Stockt____a___.___n 95210 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR JMOTHER – demolition of septic System <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 tie - into Sewer <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I" 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br />�F Operator Name Where Certified <br /> Plant Location d <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k. ordinances, stat4 and rules and regulationsl9f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> I � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT yai PER SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ July 1 &Received By July 31 <br /> ' !l BILLING REMITTANCE $ REMIT <br /> t BASE At-LANATION DATE DATE REMITTED AMOUNT DUE C,gMOU ED <br /> E FEE _ d Lf <br /> LESS <br /> PRORATION ' 01 <br /> PLUS <br /> PENALTY <br /> ` OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. IssuanceDate Mailed Delilfed <br /> r APPLICANT—RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STO KTON,'CA 9/201 <br /> 4 <br />