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Applications Will Be 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 /> Application i hereby made to carry on Pusiness in the jurisdictional area of the San Joaquin Local Health Districts <br /> Business (DBA) Address <br /> I z Owner _ Address <br /> a <br /> Firm Partners, Addresses and Teleone Numbers <br /> CL IL Business Telephone No: � � � Emergency Telephone No. <br /> IContractor Licence No. W <br /> Applicants Name (Print) Ce - Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information CLARENICE'S SEPTIC & S'ERER SERVICE I <br /> 1 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 SD. Oro ix Stockton, Calif. 95205 �r- <br /> For July 1, June 30, 19 Disposal Sites Rh•463-32 �- <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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Nest Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> o Owner W� i .SrPG�G/Y �L/ Address `ot 3 u� S� .� /vr �v� !�' C3•yNN <br /> ® SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY IM NEW 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 Y r <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 dolaccoce with San Joaquin County �p <br /> ordinances, state laws, an le d regulations of the San Joaqui Local Health District. <br /> CLARENCE'S SEPTIC & SEWER SERVICE y <br /> APPLICANT'S SIGNATURE X263 re oc ton, Calif. 95205 _ <br /> O/ Ph.463-x209 Contractor's 1 ic. 26717Z <br /> t f� _ <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 Juiy 31 <br /> REMIT <br /> BASE EXPLANATION: BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � C[,S <br /> LESS' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER 1 q <br /> r Received b l Date O Recetpt No. P rm�t o. Issu e D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E:HA AVE.,P.Q.Boa 2009 STOGKTON,CA 95201 <br />