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-�� Applications-Wil 8 Processed When Submitted Properly Completed. Be SureTo sign ineAppncaLlurl• <br /> APPLICATION <br /> " Pyr (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT f <br /> LIQUID WASTE <br /> Application ereby made to carry n siness in the jurisdictional area of the San Joaquin Local Health District <br /> E Business N m BA) <br /> Address <br /> I <br /> Owner <br /> Firm Partners, Addresses and Tele one Numbers Emergency Telephone No. <br /> 401, L00 <br /> aBusiness Telephone No. 50 4p, <br /> 4 Contractor Licence No._ J�. �G Title to <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and'Fill'in the Required information 263 So. Oro t., Stockton, Calif. 95.205 <br /> 1. ACH VEHICLE} ph.d63-3209 Contractor's Lic.X267177, <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR E <br /> For July 1,_ June 30, 19 I <br /> Disposal Sites ��l <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL, License No. <br /> Capacity Gal., Weights &Measures No. I <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 Stared I i <br /> g. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> I Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT / "eI a Z-- r,-e-t- 6 <br /> Job Address/Location ¢� p 6 4aQ % 2 G 9,V2 A&~ <br /> Owner P Address <br /> ❑ CESSPOOL W LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT -- <br /> 3 SEPTIC TANK ® REPAIR ❑ OTHER J <br /> ❑ PERMANENT ❑ TEMPORARY ® NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 016 <br /> Type Construction i Disposal Site <br /> I No. of Units Equipment Storage/Cleahing Location(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 1 SIZE: ❑ Less Than 1,000 Sq, Ft., 0 More Than 1,000 Sq. Ft. <br /> fl n_ V r.LEANING,Chemicals Used/Amount/Mo. _ ..-. I <br /> tlfnlnetlWnerc4Q1i0er►�13d .nt s iq!LatuCa rt'Cess, �efioilpylf ng>�I eft fY,thatinthe�pe or�ria,cce, jhowgklfor,�hicht his Pem trs ss,eG 7311aallnot nQterT ploy ia artlrperson <br /> iIt'svt rrlt�ftfCR"�5'lb i'fcuiTte'suble,f io tvarkrn1 'S compensation lawSol California." <br /> i p y any p r,.on <br /> COntraCtei S hiring or sub-contracting-signature'certifies-thiii"following: "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of California." <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 I nd regulations of the S Joaquin Local Health District.CLAREINCE'S SEPTIC & SEWER SERVICE <br /> 263 So. Oro * Stockton, Calif. 952b5 <br /> APPLICANT'S 51GNATURE X .1 3-3209 Contractor's Lic.#267173 <br /> GAJL4D., <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: C1 ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdBy IT�ly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> G FEE <br /> LESS <br /> PRORATION++c .F <br /> PWS <br /> PENALTY <br /> OTHER 3- <br /> OTHER <br /> Date Receipt No. _ Permit No. <br /> issuance Dale ai Delivered <br /> Received by - - '1601 E:HAZELTON AVE.,P. ox 2D09 STOCKTON,CA 95201 <br /> . _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/ ES + <br />