Laserfiche WebLink
f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />`yam (For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT i <br />i LIQUID WASTE <br />Application 1 hereby de to carry on bI,�iness in the jurisdictional area of the $ oagu Lo I Health Distriockton <br />rBusiness Name (DBA) 1 alley echanical lnc. Address �F -A �. featerloor. 11 <br />z Owner George Fleck Address 606 S Reid Linden, CA <br />Firm Partners. Addresses and Telephone Numbers --- 209931-11031, Vernon Stirm, 3122 Polk Way, Stockton, Ch <br />Business Telephone No. 2091931-4031 Emergency Telephone No. <br />Contractor Licence No. #333319 1 <br />e Applicants Name (Print) George' Fleck Title President Date 10-30=79 <br />—Please check Applicable Category (1-T) and 'F'111 In the Required Information 0 x <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. <br />Capacity <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. Name <br />Test Location <br />Gal., Weights & Measures No. <br />CAL. License Renewal No. <br />R.S. or R.C.E. No. <br />Test Date/Time <br />1 <br />4. M SANITATION PERMIT <br />Job Address/Location 2393 E Lathrop ftoaad, Manteca, CA <br />Owner MJkR Spel ye Address same as abomp <br />*A3 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD_ ❑ SEEPAGE PIT ❑ -PACKAGE-PLANT <br />❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER **1,900 gallon tank- Y <br />r 9 CHEMICAL TOILETS For July 1, - June 30, 19 •,. <br />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 I —— Where Certified — <br />Plant Location <br />Plant Capacity ' <br />T. ❑ LAUNDRY For July 1, - June 30, 19 I <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft <br />❑ DRY CLEANING, Chemicals Used/AmounVMo. <br />No. Units Served e <br />t <br />t ,'' b <br />I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations of the <br />San Joaquin Local Health District. ; <br />APPLICANT'S SIGNATURE X <br />I FOR DEPARTMENT USE ONLY <br />EITONAYE <br />Fee IS Due: ❑ ANNUALLY' ❑ PER UNIT PER SITE ❑ EACH ❑ January 1.8 Received By January 31' ❑ July 1 8 Received By July 31 <br />- <br />- <br />REMIT <br />BASE <br />.l <br />EXPLANATION BILLING REMITTANCE $ <br />AMOUNT DUE <br />CHECKED <br />DATE DATE REMITTED <br />AMOUNT <br />— <br />FEE <br />16 <br />LESS <br />? f <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />\ —•- <br />OTHER <br />` <br />"7 9 -9 to �.. �= t V 1/-71 <br />Received try Date }� Rept No. Permit No. Issuance Date Mailed Delius <br />Receipt <br />PO a 200Y' 13T0 ON � <br />• APPLICANT -RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E. HAZ ox <br />