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" Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. APPLICATION1 (Far Non-Transferable, Revocable, and Suspendable), ,y SEPTAGR V ENVIRONMENTAL HEALTH PERMIT LIQUID WASTE Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District y Business Name (DBA) ox s X -,1WL Address -2 6 3 411, oRa a Owner._ Address 47;1w@ J J Firm Partners, Addresses and Telephone Numbers - aBusiness Telephone No, Emergency Telephone No. __ "„ Contractor Licence No. 90 a2 L Applicants Name (Print) « Title e0�r� . Date02-93 eZ Please check Applicable Category (1-7) and Fill in the Required Information CLARENCE'S SEPTIC :& SEWER SERVICE 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Ora 4L Stockton, Calif. 95205 c;� For July 1, June 30, 19 Disposal Sites Ph, 43-3?109 Contractor's LarT27177 Description(Make/Yr., Color) Serial No. CAL. License No. CAL. License Renewal No. Capacity Gal., Weights & Measures No. Equipment Parking Address 2. ❑ PUMPER YARD For July 1, June 30, 19 No. of Vehicles Stored No. of Chemical Toilets Stored 3. ❑ PERCOLATION TESTI R.S. or R.C.E. Name R.S. Or R.G.E. No. i Test Location Test Date/Time 4. XSANITATION PERMIT Job Address/Location - ��fi G e Ch 4? y X ,Ri • S OwnertU. ZP74 7q 2 6 A f,6&_ pAddress �� Y AE 7'�f-(,t1L ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD XSEEPAGE PIT 0 OTHER PI ANT r tic , ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ! �- �' 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 /- -ew 7' Pie" ` _2� X Type Construction Disposal Site No. of Units Equipment Storage/Cleaning Location(s) 6. ❑' PACKAGE TREATMENT PLANT For July 1, -June 30, 19 F Operator Name Where Certified Plant Location r Plant Capacity No. Units Served ' h 7. ❑ LAUNDRY For July 1, -June 30, 19 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. MIST. E El DRY CLEANING, Chemicals Used/Amount/Mo. ,�.-•, �-' •"��[,�-/.y'� � '' 3N AV iA® a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J ordinances, state laws, and ruLes an egulations of the San Jo quin Loc Health District. f SEPTIC & SE'WER SERVICE APPLICANT'S SIGNATURE X c.;Kfcn Callf. 95?05 Q� r� �,�..•IE,J._�r��' r.��7i'.',.i C+f�i''a�iL. „'�'��Ji]] 7 FOR DEPARTMENT USE ONLY ; Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE REMIT 5 BASE EXPLANATION PATE PATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE.. LESS PRORATION V s PLUS PENALTY OTHER - ! OTHER Received by Date I Receipt No- Permit No. f Issuance Te Mailed Delivered APPLICANT—RETURN'ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.-,P.O.Box 2009 STOCKTON,CA 95201