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` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (for Non-Transferable, Revocable, and Suspendable) - e <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> aBusiness Name DBA) Address <br /> aOwner Address—Z 5 Z��Ao'o - <br /> J Firm Partners, Addresses and Telephone Numbers z <br /> aBusiness Telephone No. ?" -a Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) s Title Date Date =Q <br /> al <br /> �Q <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARENCE'S SEPTIC & SEWER SERVICE 0, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Ora * Stockton, Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites Ph.463-3209 +r_:%E19r,sLie.#267R7 �>J <br /> Description(Make/Yr., Color) l <br /> Serial No. CAL. License No. CAL. License Renewal No. i <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. or R.C.E. Name R.S. or R.C.E. No. ) <br /> Test Location Test Date/Time f <br /> 4. 0 SANITATION PERMIT f ` <br /> Job Addre s/Location <br /> .x - <br /> OwnerAddress <br /> ❑ SEPTIC TANK CESSP OL y LEACHING FIELDr.SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY 11 NEW 1�REPAIR ,❑ OTHER -C <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 tom' <br /> Type Construction Disposal Site f -� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> 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. y <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> g CLARE_NCE'S SEPTIC & SEWER SE'RVII9..6 <br /> 263 So. Oro Stockton, Calif. 9S208 <br /> Ph.463-3209 Contractor's Lic.#2671 <br /> 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, a U nd regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> r <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 July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION PATE DATE REMITTED OUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 44 <br /> PLUS <br /> PENALTY 011 b <br /> OTHER r <br /> OTHER <br /> 6b- Iib s3a� � 33'� <br /> Received by date Receipt No. Plermit No Issuance Date Mailed Delivered J <br /> APPLICANT—RETURN ALL COPIES t0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />' I <br />