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� Applications Will Be Processed When SubAPPLICATIONProperly PIeteBe u � } <br /> r� (For Non-Translerable,Revocable,and Suspendable) 5EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio Eby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> F Business Na (DBA) Address 'r <br /> l z Owner `gym <br /> a <br /> Firm Partners, Addresses and Telephone Numb oe 00I I Emergency Telephone No. <br /> CL <br /> Business Telephone No. <br /> -J Contractor Licence No. Date <br /> a Title <br /> �ApplicantsName (Print) CLARENCE'S SEI~TIC <br /> Please check Applicable Category (1-7) and Fill in the Required Information 2r 3 S^ (}i0 rr St3Gi'FO[l, Cell(. 95205 <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ph P-63-3209 C^•nrratWur'S i tC,'a2671771 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> x Capacity Gal.,Weights &Measures No. <br /> f 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. or R.C.E. No. <br /> y R.S. or R.G.E. Name Test Date/Time <br /> Test Location <br /> r 4. SANITATION PERMIT l i 1� <br /> Job Address/!- cation -41 <br /> Owner Addres r <br /> SEPTIC TANK CESSPOOL LEACHING FIELD J^� SEEPAGE PIT 11 PACKAGE PLAN <br /> � ❑ PERMANENT <br /> ❑ TEMPORARY NEW 13 REPAIR ❑ OTHER <br /> s. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> 74 <br /> Operator Name <br /> Plant Location <br /> - No.-Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE'. 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq..Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> ' R <br /> . .� <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 ule nd regulations of the San Jo n Local Health District. CLARE- — <br /> APPLICANT'S SIGNATURE X 263 So, pro Stockton, Ca € 95205 E <br /> Ph.463.3209 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: [],,ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received BY uIy- <br /> EMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMI TED - - - AMOUNT <br /> FEE S- o �* <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> x_ <br /> Permit ta Issuance Dae Mailed Delivered <br /> 1 ei by Date. Receipt No. <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERYICES.. <br /> 1501 E.HAZELTON AYE.,P.D..Box 2009 STOCKTDN,CA 95201 <br /> h <br />