Laserfiche WebLink
."pllcallons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> M ENVIRONMENTAL HEALTH PERMIT <br /> f LIQUID WASTE <br /> Application i hereby made to car 6n business in the jurisdictional area of the San Joaquin L al Health District <br /> Business N rqe BA) 't Address. ^ <br /> aOwner - Address r <br /> Firm Partners, Addresses an�,phn,�Numbers <br /> aBusiness Telephone No. d Emergency Telephone No, <br /> Contractor Licence No.Applicants Name Name (Print) Title ���/ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARENCE'S SEPTIC &; SEWER SERVICE U <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Ora * Stockton, Calif. 95205 G <br /> Ph.463-3209 Contractor's tic. t26 <br /> For July 1, June 30, 19 Disposal Sites � 1}.7A <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. <br /> T—R.S. or R.C.E.Name R.S. or R.C.E. No, <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address! cation Q <br /> r)——r <br /> Address <br /> EPTIC TANK ❑ CESSPOOL CTILEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY P114 EW El REPAIR ❑ OTHER 6 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where'Certified <br /> Plant Location <br /> F —Plant Capacity No. Units Served <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 /> k <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, rul and regulations of the San Joaquin Local Health District. <br /> ' APPLICANT'S SIGNATURE X CLAREPICE'S SEKIC, SEWER SERVICE <br /> 263 So. OTO Stockton, Calif. 95205 <br /> Ph.463-3203 GR[itr4UlRr'S l:ic• `2QAIJ- { <br /> 1 FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Race}ved By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ; BASE EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - AMOUNT - - <br /> f FEE ys TMJ <br /> LESS <br /> fff PRORATION f <br /> I PLUS '� y <br /> PENALTY 0 <br /> OTHER <br /> - <br /> OTHER <br /> Received by ate. , _ --Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO' ''ENVIRONMENTAL HEALTH PERMITISERYICE `,- ^.""' � 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />