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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> U (For Non-Translerable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 0 ' LIQUID WASTE <br /> Appl icationA herey made to carry on business in the jurisdictional area of the San Joaquin L al Health District <br /> yBusiness Na e ( A) I Address <br /> i z Owner Address <br /> 4 <br /> J Firm Partners, Addresses and I phone umbers <br /> I& Business Telephone No. - � Emergency Telephone No. <br /> Contractor Licence No. <br /> f Applicants Name (Print) e e Title Q' Date <br /> Please check Applicable Categoryi(1-7) and Fill in the Required Information CLARENCE'S SEPTIC & SEWER SERVICE <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 $0. Oro . <br /> $to i;ton, Calif. 9520 <br /> For July 1, June 30, 19 !�� Disposal Sites <br /> Ph. 403-3209 Col.1raclot's Lic. 267i77 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. Tom" CAL. License Renewal No. <br /> I 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 �r <br /> No. of Chemical Toilets Stored _ <br /> c 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 j1�1 <br /> Job Address/Location /O R P/ J <br /> I Owner. a 2 n Address sl� 9I0 a 13 r! A_�T" - C_ C AIPI.2ff <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW 13 REPAIR ❑ OTHER <br /> ` 5. ❑ CHEMICAL TOILETS For`July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units I! Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PhLANT 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 O <br /> SIZE: ❑ Less Than 1,000 Sq.'!�Ft., ❑ More Than 1,000 Sq. Ft. <br /> . 0 <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 iiccordance With San Joaquin County <br /> ordinances, state laws;p'and dales regulations of the San Joaquin L al Health District. <br /> APPLICANT'S SIGNATURE X ,if1 CLARENCE'S SEPTIC s� SEWER SERu1E15 <br /> r' 263 so. Ord i> Stockton, Callf. <br /> 'i EXU Ph.463-3209 Contr4ctor's 02. 4r267174 <br /> FOR DEPARTMENT US LY <br /> € Fee is`Due: ❑ ANNUALLY p�; ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ 4nuary.1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> JII BILLING REMITTAfs�CE $ REMIT <br /> BASSI EXPLANATION AMOUNT DUE CHECKED <br /> N, DATE E REMITTED AMOUNT <br /> r FEE <br /> F LESS <br /> PRORATION <br /> PLUS I� <br /> PENALTYAPr <br /> 1 <br /> OTHER IIIA <br /> I` <br /> OTHER IPI <br /> m <br /> Received by fla eIe Receipt No Permit No Issuance Date Mailed Delivered ,. <br /> APPLICANT--RETUAN ALL COPIES TQ:� ENVIRONMENTAL HEALTH PERMITISERYiCES 16o1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA,952{ <br />