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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) � <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on b siness in the jurisdictional area of the San Joaquin Local HBalt District f <br /> to Business Na a BA) Address G_ ? _T"' 62'!g VIE "���'' <br /> aOwner Address +� X. <br /> Firm Partners, AddressAandl�Eeh e mberaBusiness Telephone NoEmergency Telephone No. <br /> Contractor Licence No.dt <br /> Applicants Name (PrintTitle Date <br /> Please check Applicable Category (1-7) and Fill in the equired Information CLARENCE'S SEMIC & $fWER SER'v<ICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOIA EACH VEHICLE) 263 So. Oro Stockton, Calif. 85205 <br /> For July 1, June 30, 19 Disposal Sites Cil 4�34_4�9 yntrRC.toT'S lJo.f2!57177 t <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 /> 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 Test Date/Time <br /> 4. KSANITATION PERMIT +ti„ <br /> e <br /> Job Addres Loc ion �/7 <br /> Owner Ad re s <br /> ❑ SEP TANK CESSPOOL REACHING FIELD SEEPAGE PIT ❑ PACKAGE PLA <br /> PERMANENT OTEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site — I <br /> ti <br /> No. of Units Equipment Storage/Cleaning Location(s) i <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � <br /> i <br /> �p <br /> I hereby certify that I have prepared this application and that the Ork will be done in accordance with San Joaquin County " <br /> ordinances, state laws, and ules and regulations of th San Joa an Local Health District. w <br /> APPLICANT'S SIGNATURE X ARENCE'S SEPTIC <br /> 263 So. Oro 4 Stockton, Callf. 95205 <br /> PhC_i1C9 Con i,actor's(.ic. 926.717T <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 JWy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �S 0 C S�— <br /> LESS <br /> PRORATION ` �+ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 b <br /> Received by I Date I Receipt No Permit No. Issuance Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2D09 STOCKTON,CA 95201 <br />