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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION n �- <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby made to carry on b 'Hess in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness BA) "� Address <br /> z Owner Address <br /> a <br /> 1 Firm Partners, Addresses aresses and Te p ne Numbers <br /> �- � Emergency Telephone No. <br /> CL <br /> Business Telephone No. T <br /> Contractor Licence No. �^ f <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information CLARENCE'S SEKIC & SEWER SERVICE O(f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 so. Ori) j�L Stockton, Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites onrC2C Dr 5 IC. <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I; <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 R.S. or R.C.E. No. <br /> Test Location i' Test Date/Time <br /> 4. XSANITATION PERMIT <br /> Job Address/Location �� } <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD XSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 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. l <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, a r and regulations of the Spn Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> 253 So. Oro 4L Stockton, Cafif. 95205 <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE ' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATEREMITTED AMOUNT <br /> FEE II <br /> I LESS <br /> tit PRORATION r <br /> PLUS <br /> pw - PENALTY - <br /> 1 . <br /> OTHER <br /> OTHER <br /> 3 17�3'5i <br /> eceived by Date Receipt No. _ Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:?• ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />