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Applications Will Be Processed When Submitted Properly completed. <br /> - ,� APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL'HEALTH PERMIT <br /> LIQUID WASTE i <br /> Application is hereby made to carryon business in the jurisdictional area of the San JoaquIIIin Local Health <br /> Jat District <br /> Stockton <br /> N BusirYess Name (DBA) ss <br /> V 1 Mech nical 1nC 06 S�fePeld Linden CA <br /> Georg: Fleck Address Stockton CA 9 <br /> a Owner Vernon Stirm 12z Polk Wa <br /> I Firm Partners, Addresses and Telephone Numbers <br /> a-40 Il Emergency Telephone No. <br /> aBusiness Telephone No. )9/ <br /> J Contractor Licence No. Pr eSldCnt Date 5 [� <br /> LApplicants Name (Print) Geor e Fleck Title v <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites r <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity r Gal,,Weights &Measures No. <br /> Equipment Parking Address _ # <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ` <br /> No. of Vehicles Stored 01 <br /> No. of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> " Test Date/Time <br /> Test Location <br /> t 4. @ SANITATION PERMIT MOnrler Com anO8 S. H r1an� Stockton CA <br /> G Job Address/Location Saihe�as above <br /> Owner Att• Mr, Neil. To.nkes Address '-[],PACKAGE PLANT <br /> I ® SEPTIC TANK 13 CESSPOOL a LEACHING FIELD SEEPAGE PIT ❑ OTHER S,600 Gal. Tank <br /> 13 PERMANENT ❑ TEMPORARY IR NEW _ <br /> REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 197 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1. -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> ii No. Units Served <br /> Plant Capacity ) <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 I hereby certify thq 1 ave prepared this application <br /> and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la nd rules and eg, tiorf t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> . - ❑ ❑ EACH ❑ January i &Received By January 31 ❑ July 1 8 ReceiveRdEMI <br /> rJuly 31 <br /> Fee IsDue: C1 ANNUALLY PER UNIT PER SITE <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> i <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> dls <br /> Issu nce Date Mailed Deiive d <br /> -'Date Receipt No. - Permit No. <br /> /Z <br /> Received by 'sem - 1601 E.HAZELTON AVE.,P.O.Box 3049 STOQ TON,,CA 5201 <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />