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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Novi-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ' ENVIRONMENTAL HEALTH PERMIT N <br /> LIQUID WASTE ) <br /> Application iI:ps hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District �C �/ <br /> I sn Business Name (DBA) C, -d-. Address <br /> z Owner - Address <br /> a <br /> J Firm Partners, Addresses a Tele one IVumbe�rs�� g y p I <br /> aBusiness Telephone No. r/' s [ � Emer enc Tele hone No. _ <br /> Contractor Licence No. / C � Date 4 d <br /> L Applicants Name (Print) Title t' SEP IC & SEVVER SERVIroll <br /> ' <br /> Please check Applicable Category (1-7) and Fill in the Required Information 263 S0. Oro 'StOcktn;-'Calif. 95205 <br /> 1. El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ph,463-3269 Contractor's Llc.#�ISZWX <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,.Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD � � �f } , <br /> For July 1, June 30, 19 7 <br /> 41F <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 <br /> Test Date/Tune, <br /> 4. ArSANITATION PERMIT <br /> Job Address/Location l <br /> Ic a Address - <br /> IRwner � •- ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING'-FIELD SEEPAGE PIT <br /> PERMANENT <br /> ❑ TEMPORARY ❑ NEW `"" REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 3019_ <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> 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 . <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, an e d regulations of the an Jo un Local Health District. <br /> CLARENCE'S SEPTIC & SBV0 SERVICE <br /> APPLICANT'S SIGNATURE X �n <br /> Ph.463-3209 Contractor's Uc,#267171 <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> I Pee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Juiy 1 &Received By July 31 <br /> li REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE �fREMITTED AMOUNT <br /> FEELESS <br /> PRORATION �r�y <br /> PLUS <br /> PENALTY 1 l/ <br /> OTHER <br /> j OTHER <br /> Received by <br /> Date Receipt No. Permit No Issu nce ate Mailed Delivered <br /> 16111 E.H,gZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 952!}1. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERViCES � <br />