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Appl[caflonshWill Be Processed When Submitted Properly Completed. Be <br /> �; APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i LIQUID WASTE <br /> Applicatio f is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> - Address r;,, <br /> Business Na BA) r <br /> i OwnerAol—_ Address <br /> t 9 Firm Partners, Addresses and Tel ph ne Numbers Emergency Telephone No. <br /> f a Business Telephone No. r <br /> Contractor Licence No. <br /> C�.S Title Date <br /> Applicants Name (Print) C CLAREXE'S SEPTIC & SEWER SERVICE <br /> Please check Applicable Category. and Fin the Required Information 263 So. Oro * Srockton,'Calit. 95205 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ph-463-3209 Contractor's L+c. 267117 <br /> For July 1, June 30, 19 '1M' Disposal Sites <br /> Description(Make/Yr., Color)- I <br /> Serial No. <br /> ISM CAL. License No, <br /> GAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i For July 1, June 30, 19 aN' <br /> I No. of Vehicles Stored <br /> t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> k R.S. or R.C.E. Name Test Date/Time <br /> Test Location �M <br /> 4. WSANITATION PERMIT 'I r <br /> ` Job Addre ation <br /> ` E Address <br /> I Owner <br /> 11 SEPTIC TANK 11 CESSPOOL LEACHING FIELD -SEEPAGE PIT ❑ PACKAGE PLANT <br /> f ❑ PERMANENT ❑ TEMPORARY 13 NEW REPAIR 11 OTHER <br /> k 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction �N Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> [ 6. ❑ PACKAGE TREATMENTI�PLANT For July 1, -June 30, 19 <br /> 1. ' Where Certified rfi <br /> Operator Name J� ` 1 <br /> Plant Location ; >.�_ _ <br /> '�=�'No.'Units Served <br /> Plant Capacity y(: - <br /> il 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> F ❑ DRY CLEANING, Chemicals'IUsed/Amount/Mo. - <br /> d <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 ul nd regulations of the San Joaq in Local Health Distrltc`f,`�Ei�Jc'S SEP <br /> Cx�S-EV&ER SEr�1J10E <br /> APPLICANT'S SIGNATURE X I� E3t.403-320J C4RtrdClOrS c. 267i77 <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> ❑ July 1 Receive <br /> Fee is Due: 11ANNUALLY,, ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January-1 &Received By January 31 & R�ERnIT 31 <br /> I - 'Iji BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 1 F EES_ b, <br /> E <br /> • LESS <br /> PRORATION <br /> PLUS <br /> PENALTY e - - <br /> OTHER Ii�[ <br /> OTHER ll�i <br /> issuance Date Mailed Delivered <br /> Received by Date <br /> Receipt No. - Permit o. <br /> 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br /> APPLICANT-RETURN AL .COPIES 71': ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />