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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG� <br /> v LIQUID WASTE <br /> Applicatio ereby made to carry.2.rljwsiness in the jurisdictional area of the San Joaquin Loc I Health District <br /> wBusiness Name 91PA&A&4 A4e44,^-r Address o�G a 624!! t, r <br /> aOwner Address�,��—�_— <br /> Firm Partners, Addresses and Teellep�/one Numbers <br /> CL Business Telephone No. Sf ;,yL 9 Emergency Telephone No. <br /> Contractor Licence No. <br /> — <br /> L Applicants Name (Print) Title en�d�A�eQA6 _ Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information CLARENCE'S SEPTIC & SEVER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Ora 4 Stockton, Calif. 95205 + <br /> For July 1, June 30, 19 Disposal Sites pit 46-3-3209 Contractor's Li267171 t <br /> Description(Make/Yr., Color) - <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. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Owner •Addre s <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD XSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY X NEW ❑ REPAIR ❑ OTHER �? <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ry <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Vn <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. <br /> CLARENCE'S SEPTIC & SEWER SERVICE � <br /> 263 So. Oro -1� Stockton, Calif. 95205 <br /> PCI.41T3 ,`2109 ContrBCtor's Uc ll?67177 <br /> 1 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 regulations of the San Joa uin Local Health District. <br /> APPLICANT'S SIGNATURE X ('' <br /> t'z <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> OU <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> oe <br /> OTHER <br /> frlh <br /> Receive by Date Receipt No. Permit No. Issuance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO .,P.O.Box 2009 STOCKTON,CA 95201 <br />