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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Si nTheApplication. <br /> APPLICATION . <br /> (For Non-Transterabke, Revocable, and Suspendable SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' LIQUID WASTE <br /> i <br /> i Application is hereby made to carry n business in the jurisdictional area of the San Joaqul Local Health District <br /> rn Business Nam (DBA) <br /> Address�7_� ... � T � s'"afi . ' _r <br /> z Owner Address <br /> 4 .E <br /> Firm Partners,-Addresses and 7elep �bneNumbers <br />,!. a Business Telephone No. — � 3-" 3 Emergency Telephone No. <br /> Contractor Licence No. �� /�+' pale i <br /> a li teS Title <br />! L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill kn the Required Information <br /> CLAREi+I%E'S SEPTIC & SEWER SERu46E <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro Stockton, Calif. 95205 <br /> For July 1, June 30, 19 <br /> i Disposal Sites P11. 463-32.09 Con'rarter's I_ic. '�7.67177: <br /> I <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 /> l 3. ❑ PERCOLATION TEST R.S. or R.C.E. No.R.S.or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT 4 <br /> k Jab Add r Location <br /> _ Address <br /> Owner <br /> SEPTIC TANK © CESSPOOL LEACHING FIELD - ArSEEPAGE PIT ❑fPACKAGE PLANT <br /> X. PERMANENT ❑ TEMPORARY rime ❑ REPAIR ❑ OTHER Y <br /> 5. ❑ CHEMICAL TOILETS For July i, -June 30, 19 <br /> Type Construction M Disposal Site <br /> No. of Units <br /> Equipment Storage/Cleaning Location(s) <br /> f� i <br /> 6.... 13 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> [ 3s <br /> Plant Location-_ <br /> Plant Capacity„ v 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 /> 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 la7X� <br /> regulations of the San Joaqu Local Health District. CLARENCE'S F <br /> if <br /> APPLICANT'S,SIGNATURE X Z53 So. Oro � Stockton, Ca1jf. 95205 <br /> Ph.463.3'209 Contra,_,, X267' <br /> FOR DEPARTMENT USE ONLY <br /> a, ' <br /> - Fee IS Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE *EXPLANATION - DATE DATE REMITTED C - AMOUNT <br /> 4 A . <br /> FF{ + ' FEE <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r OTHER <br /> E <br /> OTHER <br /> 63 <br /> M7? !7 p 1 <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Er: ... <br /> .�- - APPLICANT—RETURN ALL-COPIES TO:'1 � ENVIRONMENTAL HEALTH PERMIT/SERVICES � 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON, <br />