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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> f APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio reby made to carryon busi ss in the jurisdictional area of the an Joaquin Lo I Health District <br /> yBusiness N e A} Address <br /> z Owner11 <br /> Address <br /> a <br /> J Firm Partners, Addresses and Te hone umbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print} Title �C �! j e Date — 1 <br /> L CE'S E'7, & SEI'EP, SER�!IGE <br /> Please check Applicable Category (1-7) and Fill In the Required Information 263 So. Cro ,, Stockton, CtY. 9520,5 1�a <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ph,463-3209 CDn.f2 t i'S Lir.�L;,;1' <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. <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. ❑ SANITATION PERMIT <br /> Job Address/Location 176 23 T �. 3 �SC AFX 0,41 <br /> Owner VO K[i AL 11"7L� Address <br /> M SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> -S) <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. r'1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> y <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, andr es and regulations of a tPJoaqui ocal Health District. <br /> APPLICANT'S SIGNATURE X CLARENCE'S SEPTIC & SEWER SERO!(SE <br /> 263 So. Oro Sta-ton, Calif. 95205 <br /> Pit.463-3209 Contractor's Lic.#'Lb717.3 <br /> rte'/_ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY Cl PER UNIT u PtR SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER h <br /> OTHER ' , QtJd� <br /> Issuance Date Mailed Delivered <br /> eiv8d_by Date Receipt No. Permit No. <br /> APPLICANT—RtfURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZEL70N AVE.,P.O.Box 2009 S70CKTON,CA 95201 <br />