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.� <br /> � Ions Will Be Processed When Submitted Properly Completed.-Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ,.. SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> a LIQUID WASTE. <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin L cal Health District <br /> HBusiness Name DBA) J— Address <br /> z Owner - <br /> Address �` <br /> a <br /> 2 Firm Partners, Addresses and T iephon Numbers <br /> J ,7._ 3 2 � f Emergency Telephone No. <br /> r a Business Telephone No. <br /> Contractor Licence No. �. <br /> �PTitle Date <br /> f <br /> Applicants Name (Print) CLARENCE'S SEPTIC & SEWER SERVICE � <br /> f Please check Applicable Category (1-7) and FIII in the Required Information 263 So.'Oro ji�- Stockton, Calif. 95205 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) PI, A�,� (C;n;`rp c <br /> Disposal Sites 9. &or'. Li "267177# <br /> For July 1, June 30, 19 p <br /> Description(Make/Yr., Color) <br /> CAL. License No. GAL. License Renewal No. <br /> Serial 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:a❑ 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. XSANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> 13 SEPTIC TANK' CESSPOOL ❑ LEACHING FIELD $SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1:1PERMANENT ❑ TEMPORARY 1:1NEW XREPAIR ❑ OTHER Ci <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> lant Location <br /> Plant Capacity r No. Units�erved <br /> . ❑ LAUNDRY For July 1,-June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <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, an�s Z regulations of th an Joh i�al Health District. <br /> o-n:rF'S SL7PTtC & SEINER SERVICEAPPLICANT'S SIGNATURE X Q520 <br /> 263 S0. 0r0 StoCktCalif. 7I <br /> FOR DEPARTMENT USE ONLY - <br /> FFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE [3 EACH El January i &Received By January 31 ❑ July 1 &ReceiveRdEMITuly 31 <br /> BASE EXPLANATION BILLING REMITTA E $ - AMOUNT DUE CHECKED <br /> DATE DAT REMITTED AMOUNT <br /> 5 <br /> O O <br /> FEE <br /> LESS <br /> Al <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> P <br /> OTHER <br /> Cup— <br /> Received by D e Receipt No. Permit No Issuance Date Mailed d <br /> 1fil]7 E.HAZELTON AVE.,P.O.tiox2o99 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> I <br />