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- — 4 <br /> Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> 5, , <br /> Applicatio�i ereby made to carryon sin in the jurisdictional)area of the San Joaquin Local Health District .J <br /> yBusiness N e DBA) Address p <br /> i Owner 1l <br /> ae Numbers <br /> Firm Partners, Addresses and Tell .3 a V Emergency Telephone No. <br /> aBusiness Telephone No. �� <br /> Contractor Licence No. 1P�L - Title (9 ate <br /> �Applicants Name (Print) CLAREf�CE'S Sr TIC & S"�1�J R SERVICE -6— <br /> Please check Applicable Category (1-7) and Fill in the Required Intormation 263 So. aro 4 Stockton, Calif. 9520.5 <br /> 1. [1PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) p){,463-3209 <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No- <br /> CAL. License No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br />'I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> i. 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time 11c: qRl <br /> Test Location <br /> { q. SANITATION PERMIT <br /> 1I Job Address/Location Address <br /> 1 Owner LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> l ❑ SEPTIC TANK ❑ CESSPOOL ❑ OTHER �y <br /> 11PERMANENT <br /> 13 TEMPORARY ❑ NEW REPAIR \ <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 1Dlspasal Site <br /> [ Type Construction <br /> I No. of Units Equipment Storage/Cleaning Locations) <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 <br /> More Than 1,000 Sq. Ft- <br /> SIZE: El Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ^ <br /> e ulations of th an Joaquin c I Health District. <br /> ate, ,;., S. <br /> ordinances, state laws, and 9 <br /> i APPLICANT'S SIGNATURE X Ph,463-3209 Qbl'i aCto Lic. -Zoi 1771 <br /> t FOR DEP RTMENT USE ONLY <br /> r r� REMIT <br /> 31 <br /> Fee IS DUB: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 [3 July 1 8.Recei�el�d CKEDBy y <br /> ❑ u <br /> BILLING REM1iTTANCE AMOUNT DUE AMOUNT <br /> r BASE EXPLANATION DATE DATE EMITTED <br /> FEE °7 i <br /> LESS <br /> Y. PRORATION <br /> Ir PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> q SoZs� 1 <br /> I X a{� � � Is uance Date Mailed eliver d <br /> / <br /> Receipt No. Permit No. <br /> k <br /> Received b Dat 1601 E.HAZELT <br /> APPLICANT--RETURN ALL COPIEON AVE.,P.O.Box 2008 STOIC ON.CA 5207 <br /> S'TO: ENVIRONMENTAL HEALTH PEAMIT7SERVIC <br />