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Applications Will Be Processed When Submitted Properly Completed.BeSureTo Sign Ine#%ppucarwr,. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> '±. ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> �Apcati i hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health DistrictBusiness ) Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> a - , <br /> Contractor Licence No. ' <br /> LApplicants Name (Print) <br /> ��e <br /> Y Title <br /> Please check Applicable Category (1-7)and Fill in the Required Information 263 S0. Oro Stockton, Wit 95205 _/� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ph.463.32(}9 Contractor's Lic.J26717Z C� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) ' CAL. License Renewal No. <br /> Serial No. CAL.."License No. <br /> I Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored • ry. <br />[ 3. ❑ PERCOLATION TEST <br /> tk R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 1• ,� <br /> 17 77 <br /> Job Address/Location iv —� u � <br /> I Owner 4 07 `SS Address �' � H Rd L <br /> ® TIC TANK CESSPOOL 10 LEACHING FIELD 1:1 SEEPAGE PIT ❑ PACKAGE PLANT �bocx .-�...A. c- <br /> F SEPE] ❑ REPAIR , <br /> ❑ PERMANENT ❑ TEMPORARY ® 'NEW � OTHER yJ faQe, <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i 4 <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 /> Where Certified <br /> Operator Name <br /> I <br /> Plant Location <br /> k <br /> No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ti ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i I hereby certify that I have prepared this application and that the work will be done in accordance with Sall Joaquin County <br /> ordinances, state laws, a ule and regulations of the San Joaquin Local Health District. CLARENCE'S SEPTIC & S'EKII SERVICE <br /> r 263 So. Oro Stoclacn CaNt S5205-- <br /> APPLICANT'S SIGNATURE X Ph-463-3209 Contractor's Lic.#267172 <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Fee Is Due: ❑ ANNUALLY -❑ PER UNIT El PER SITE EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &ReceivedREMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT _ <br /> C' <br /> FEE <br /> LESS <br /> k PRORATION - - <br /> PLUS <br /> t PENALTY <br /> F OTHER <br /> OTHER <br /> Date Receipt No. Permit No, Issue e D to Mailed Delivered <br /> Received by - <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.-HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />