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HEAP iicaiions Will be PrOck:?Shvu killtiil .:au. ...,:... . •�r�••+i _ ,? e: <br /> APPLiCAT1ON <br /> (Far Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> y Application is Hereby made toCarry on business in the jurisdiction al area of the 5a oaqu Loc h Distric� f� / <br /> L , v r> . _ Address— <br /> �Business Name DBA) .f"` <br /> / . / <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. r <br /> 'Q Contractor Licence No. J � r s` '� .Title Date c~- <br /> / ted <br /> `L Applicants Name (Print) -�^ CLAREi1'CE'S SEPTIC & SEWER SERVICE <br /> Please check Applicable Category(1-7)and Fill in the Required Information � , <br /> 263 5o.'OrD � ock <br /> Stfon,'.Ca'aif.-95205 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Phi3-3209 Cop; ^ <br /> For July 1, June 30,19 Disposal Sites <br /> Description(Make/Yr., Color) CAL.License Renewal No. <br /> � �+ <br /> Serial No. CAL. License No. <br /> Capacity Gat.,Weights & Measures No. --�1 <br /> Equipment Parking Address i <br /> t 2. ❑ PUMPER YARD <br /> i For July 1, June 30,19 <br /> No..of Vehicles Stored t I� <br /> 'No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST A.S. or R.C.E. No. <br /> A.S. or R.C.E.Name Test Date/Timt ' <br /> Test Location <br /> ; . <br /> € 4.� SANITATION PERMIT � ,;� /r / �F,, �- � ? � --- <br /> Job Address/Location m V <br /> i 1 :_r _ 7711 <br /> Address <br /> Owner ❑ -PACKAGE PLANT <br /> ❑ SEPTIC TANK �CESSPO �+ LEACHING FIELDSEEPAGE Pt 1~ ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW O REPAIR 0 \ <br /> II <br /> S. ❑ CHEMICAL TOILETS -For.July I,, June 30, 19 t <br /> tType ConstructionDisposal Site <br /> No.of"Units Y Equipment Storage/Cleaning Location(s) x <br /> t 6 <br /> 6. ❑A PACKAGE TREATMENT PLANT 'For July 1, -June 30, 19 ` Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units'',ISei•ved. - <br /> 'Plant Capacity L <br /> ❑.LAUNDRY For July 1,-June 30, 19 r , <br /> SIZE: El Less Than 1:000 Sq.Ft.,. , ❑ 'More Than 1;000 Sq.Ft. w r F <br /> ( ❑ DRY CLEANING,'Chemicals Used/Amount/Mo, , <br /> epared this application and that the work will be done in accordance with <br /> ! hereby certify that 1`have prSan Joaquin County <br /> ordinances,state lawsrl�e�s,and_regulations of the San Joaquiq Local Health Distr ,tAEfSCES •SEPTIC $t $EWER SE.riVjCE/ 1�APPLICANT'S SIGNATUREX_, `t kvf i - <br /> on; a <br /> Ph:463-3209 'Contractor's Lic.X261171, <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH II ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT 't <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED I <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS xP <br /> PRORATION i <br /> PLUS ¢ <br /> PENALTY - _ / % <br /> t OTHER A <br /> I iM OTHER <br /> _ SDS �� r <br /> Receipt No- v Permit No. * Issuance Date Mailed Delivered <br /> Received by D to 1 <br /> 1601 E.HAZ€ETON AVE.,P.O.Bac 2008 STOCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: 15NVIRONMENTAL HEALTH PEFtm./SEPiYIC S <br /> 'I s, <br />