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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION J <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 0(1 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE � <br /> Application is here y made to carry on business in the jurisdictional area of the San Joaquin Local Health District �Y <br /> rn Business Name (DBA �R�&?etA .Q4Tre 'e,< Address ? 'i s—i 0A'47, <br /> z Owner Address 7 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> I <br /> Business Telephone No. ! •J'`�- ' Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ` .� �'� —, ) Titie '/�'7`/�!4 6 Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information CLARE."•ICE'S SEFIC & SEVIER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 SC. G ] SiC;!,Jon, C3'if. 95205. <br /> For July 1, June 30, 19 Disposal Sites Fh j ca ;;2x7171 <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 /> j, <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 <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD WSEEPAGEPIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 1W 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. <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, and rules an Ions of the San Joaquin Loca ealth District. <br /> CLAREfdCE'S SEPTIC & SEWER SERVICE <br /> APPLICANT'S SIGNATURE C S). to me StC ktOn, 2,'if. 95205 <br /> Ph. _ J,,9 CO2t adw 's Lic. -267174 <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> u ( AMOUNT <br /> FEE X/J5 <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY ` <br /> OTHER <br /> OTHER <br /> 63303 9,6 ? o� <br /> Received by Date Receipt No. Permit No. Issuan Date Mailed Del iv red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON, A 95201 <br />