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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �rt (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT l <br /> LIQUID WASTE <br /> Applicationns ereby made to carry on iness in the jurisdictional area of the San Joaquin Local Health District f r �� <br /> NBusiness IN e BA) -� Address G <br /> I- Address S <br /> a Owner <br /> ().Firm Partners, Addresses and Te eph ne Numbers 1 <br /> CL Emergency Telephone No. <br /> IL Business Telephone No. —. <br /> a � <br /> _J Contractor Licence No. <br /> Title �,( r — Date <br /> L Applicants Name (Print) rnJrr <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> CLARE'�CE,2C3 S SEPTIC & U,1VER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ph-4--.3-K09 <br /> �hy�-4 S0. �n/f0n G Stockton, Calif. yS2i15 �l 1 <br /> rii-�f=iJ.��iJ� <br /> For July 1, June 30, 19 Disposal Sites �J <br /> Description(Make/Yr., Color) y <br /> CAL. License No. CAL. License Renewal No. <br /> SerialNo. J <br /> II <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 II <br /> No. of Chemical Toilets Stored <br /> i <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. ASANITATION PERMIT <br /> Job Address/Location <br /> Owner Address 67 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD `SEEPAGE PIT <br /> ❑ PACKAGE PLANT <br /> PERMANENT 11 TEMPORARY <br /> , NEW 13 REPAIR OTHER <br />€ 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Is <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 /> Plant Location <br /> Plant Capacity No. Units Served r^ <br /> it V y <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> II <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More Than 1,000 Sq. Ft. '! <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. " <br /> �! R <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,' and regulations of th San Jo uin Local Health District. <br /> CLARE.1dCE'S SE'I'T?C & KW r , IE <br /> APPLICANT'S SIGNATURE X �3 SQ. CtfU �F SCCCItI 11, Ca if. 95205 �I <br /> Ph.463.2209 Cc,r,t- ._;r's:_i� -k257177 li <br /> { FOR DEPARTMENT USE ONLY II� <br /> Fee Is Dile: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JL <br /> Iy 31 <br /> - REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT I <br /> FEE 1 <br /> LESS <br /> PRORATION J <br /> PLUS I r <br /> PENALTY y <br /> OTHER IIP <br /> OTHER i �I <br /> Received by ate Receipt No Permit No. Issfiance Wate Mailed Deliver <br /> 1. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON;CA 95201 _f <br />