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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. 4 <br /> �- APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> JJ7� �• ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application js hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name DBA <br /> F ( )���C.'f'i.,Q .S'Q477 C .4—rye e,J a eC���a dd ress .Y r C <br /> a Owner Address-.2 1� 3 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. J.2 ri. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date °'3 <br /> Please check Applicable Category (1-7)and Fill In the Required Information CLAIREIYCE'S SEPTI% & SEWER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 253 SQ. Oro u Sicdet`,,n, Calif, 95205. <br /> For July 1, June 30, 19 Disposal Sites Ph,4(1.3.3209 Con,ractot'S Lit;.725717]1 <br /> Description(Make/Yr., Calor) <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. or R.C.E. Name R.S. or R.C.E. No. Q <br /> Test Location Test Date/Time <br /> 4. A SANITATION PERMIT <br /> Job Addre s/Location -� <br /> caner AddressA r �1 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY WNEW ❑ REPAIR OTHER WXC/fCI%e <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. a '- <br /> ;1. <br /> .t <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, and r les a regulations of the San Joaqui Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 253 952175 <br /> air <br /> Lie.=,26717,71 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due'. ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 i <br /> Y Y Y July 1 &Received By July 3t <br /> B - REMIT <br /> BILLING BASE EXPLANATION `7 R ITTANCE ., $ AMOUNT DUE CHECKED <br /> _ iii <br /> DATE �I} DA_fE REMITTED 4i AMOUNT_ - <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER A <br /> ------------ <br /> 1 Ca 3 <br /> Received by Dae Receipt NOL Permit No- Issuance Date Mailed I a iv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Bo: pp9' S .0 TON,C 5201 , <br /> Y <br />