Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign <br /> APPLICATION <br /> ~� �~ (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ct <br /> Application is hereby made to carry on business in the jurisdictional area of the S aq inE.Local Health <br /> rToo, Stockton <br /> N Business Name (DBA) Valle Mechanical Inc- 646 S.ddress 3 Reid Linden CA !1 <br /> Address %s <br /> aOwner Geor Fle_cStockton,_ <br /> J Firm Partners, Addresses and Telephone Numbers Vernon Stirm 122 POl Way, CA <br /> 2O � 3� �11Q l Emergency Telephone No. , <br /> aBusiness Telephone No. l <br />.�Contractor Licence No. GeOr e Fleck Title _ P j�d nt Date -� <br /> Applicants Name (Print) <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) # GAL `Lic nse Renewal No. <br /> Serial No. i CAL. License No. F <br /> Capacity : Gal.,Weights &Measures No. - a <br /> t <br /> Equipment Parking Address t A <br /> 2. ❑ PUMPER YARD LAI <br /> For July 1, June 30, 19 f Q <br /> A. <br /> No. of Vehicles Stored 1 N <br /> No. of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Tesf;Date/Time . <br /> Test Location <br /> 4. SANITATION PERMIT <br /> Joh Address/Location di Wa Stockton CA <br /> Owner G Address ; <br /> SEPTIC TANK 13CESSPOOL 1 LEACHING FIELD SEEPAGE PIT C1 PACKAGE PLANT <br /> € ❑ PERMANENT ❑ TEMPORARY C 'NEW <br /> - ❑ REPAIR <br /> ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction - <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July i, -June 30, 19 Where Certified <br /> Operator Name 6 <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> j SIZE: 13 Less Than 1,000 Sq. Ft., © More Than 1,400 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I he y Y - <br /> ordinances, state laws, and rules and regulations of the SarifJoaqu' Local Health District. <br /> l APPLICANT'S SIGNATURE X <br /> i <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received REMITJuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> k BASE EXPLANATION ()ATE DATE REMITTED AMOUNT <br /> FEE I <br /> LESS <br /> PRORATION <br /> PLUS k <br /> PENALTY \ <br /> [ OTHER 1\0 <br /> `D <br /> r' <br /> OTHER <br /> �I� 79-77 <br /> Receipt No. r I o. Issuan a Date Mailed Delivered 1JeZ},(Y <br /> eceived•by Date �' <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -- <br /> ]601 E.HA2ELTON AVE.,P.O.Bo�-2009 STOCKTON,CA 9 20 <br />