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Applications Will ¢e Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is hereby made to carr o business in the jurisdictional area of the San Joaquin ocal Health District <br /> yBusiness Name (D A) B Address _—z <br /> aOwner Address IdA. <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> aBusiness Telephone No. 2 Q Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date —� <br /> Please check Applicable Category (1-7)and Fill in the Required Information CLARENCE'S SEPTIC & SEWER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro * Stockton, Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites <br /> Ph.463-3209 , <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 0 <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/Lo atio <br /> Owner r Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL" LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT ` <br /> ❑ PERMANENT ❑ TEMPORARY , NEW fiT REPAIR ❑ OTHER \(1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t� <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 /> CLARENCE'S SEPTIC & SEWER SERVICE <br /> 263 So. Oro * Stockton, Calif. 95205- <br /> Ph, <br /> 5205Ph.463-3209 Contractor's Lic.rA267171. <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 le nd regulations of the San Joaqu�Health District. <br /> APPLICANT'S SIGNATURE X j <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE. $ <br /> BASE EXPLANATION DATE D TE REMITTED AMOUNT DUE CHECKED <br /> Lr _ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION Vw <br /> PLUS <br /> PENALTY ft <br /> OTHER i <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssuanc&Qao Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />