Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ <br /> APPLICATION <br /> �.. (For Non-Transferable, Revocable, and Suspendable) <br /> tsr ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is herebymade to carry on business in the Jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA)_ Valley Mechanical Inc Address 4634A E . Waterloo Rd . Stockton <br /> Owner George J. Fleck Address 606 S. Reid Ave. <br /> 3 Firm Partners,Addresses and Telephone Numbers Same As Above - <br /> Business Telephone No. 931.4031 Emergency Telephone No. 462-2905 <br /> Contractor Licence No. 333319 <br /> Applicants Name (Print)— Jim Haley Title Estimator Date 2�S�B2 <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) t <br /> Serial No. _ CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity ;. » Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. •❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> •.No. of Vehicles Stored -No. of Chemical Toilets Stored <br /> 3. Cl PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> d. ❑ SANITATION PERMIT <br /> Job Address/Location 36 W. Matthews Rd Stockton. CA. <br /> Owner Silva Properties Address 2119 West Alpine o k on 95204 <br /> ®: SEPTIC TANK ❑ CESSPOOL © LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW „ 0 REPAIR ❑.OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 -. <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 /> I hereby certify that I he repared this ap li otic,; and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws• a d r les and regula o soft an aqui; Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r'ca O <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH i] January 1 8 Reciuvcd By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S 4\ tl^ e / t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY -. <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date 'Mail Delivemd, <br />