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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIf}WASTE a <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) Valley Mechanical, Inc. x `Address,.. P;1]-Rnv 519E Stockton, CA _ <br /> aOwner George Fleck Address .P h Rn,r 517At Sirif-kfnn,' CA 95205 ' <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. . 209-931-4031 Emergency Telephone No. 209-462_2905 <br /> -J Contractor Licence No.'� <br /> Applicants Name (Print) Tim Haley 'Title E .imatnr -' Date <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. s <br /> Equipment Parking Address <br /> 2. ❑ 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..Narne R.S. or R.C.E. No. <br /> Test Location u. Test Date/Time <br /> 4. tA SANITATION PERMIT C 2:6 0 Pte- _ <br /> Job Address/Location <br /> Owner Ihar]nwe PropertiaG Address ` <br /> ❑ SEPTIC TANK ❑ CESSPOOL )Q'LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR © OTHER Y <br /> 5. Q 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 r <br /> Plant Location { <br /> Plant Capacity No. Units'Served <br /> 7. ❑ LAUNDRY For July !, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More.Than 1,000 Sq. Ft. <br /> ❑ D_RY CLEANING, Chemicals Used/Amount/Mo. <br /> Hgrllerrwnerorile©navdapvnVsrlgnntu+evert,%9lsthe folln- in Icerfifvth3t41tP>a erforman:caftl:cworkforv,hichthisPermitisissued,lshallnotemployanyperson � <br /> t <br /> III SUCh manner as to become subject to viorhman's Conlpensai'sor,taws of Ca(iforrla x E? „ <br /> Cor tractor'3 hf:inp or 5u17-E9ntraL?sng segrinit3ro certifies xlie folfouving; "(certilp tllal in the'perlom mano of the work for which LNs permit is issued,I shall i <br /> emplfly persons subject to vrorktrian's compensation laws of California:': � ! <br /> I hereby certify that I repared ethispljc'�' nand that the-work will be done in accordance with San Joaquin Countyordinances, state law and les and ron the San Joaquin Local Health District. ; � <br /> , �. <br /> APPLICANT'S SIGNATURE X ` <br /> p. <br /> X 'FOR DEPARTMENT USE ONLY <br /> T P <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Rece+ved By January 31 ❑ July 1 &.Received By July 31 <br /> .. _ REMIT _ <br /> BILLING _ REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - - AMOUNT <br /> FEE VP <br /> LESS <br /> PRORATION �7 - <br /> PLUS <br /> PENALTY <br /> OTHER 3 +� <br /> OTHER <br /> Received.by Date Receipt No. Permit No IssPantelDate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br />