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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 /> -` i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA)_1!L/yRENe- Address - ;2 63 •5a Odd 57'"o a�P�ow <br /> a y_ <br /> Owner LA.i2F� -S / 4,fy h F�' Address <br /> Firm Partners, Addresses and Telephone Numbers i <br /> m Business Telephone No. ?-;? 0 _ Emergency Telephone No. <br /> R <br /> Contractor Licence No... 2 6 7/2 7 <br /> Applicants Name (Print) G-;' .V S Title Date ! <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARENCE'S SEPT;C & SEWER SERVICE c>6i <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) .263 So. Oro 4 Stockton, Catrf. 95205 <br /> For July 1, June 30, 19 Disposal Sites P3�`iC3-�tEn�r {Fr i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity— Gal., Weights &Measures No. <br /> 1 <br /> Equipment-ParkingAddress ' <br /> 2. 11 PUMPER YARD <br /> For July 1, June 30, 19 x <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 _ 1 <br /> Job Address/Location <br /> Owner F R O*e 96 Of 5 ¢S Address l O '6";VRk <br /> Ad <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD--❑ SEEPAGE PIT ❑-PAC AGE-PLANT OV <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW X REPAIR ❑ OTHER �JS <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipmenf_Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19Y <br /> Operator Name Where Certified <br /> Plant Location t <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. i �~ <br /> i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Ma. :M'F r;T`,` Je: <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, a lepiand regulations of the an Joaawn Local Health District. <br /> APPLICANT'S SIGNATURE- CLARENCE'S SEPT;C & SCWER SERVICE _ <br /> 263 So. Oro Stockton, Cafit. 95205 <br /> 449 Ph.453-3209 Corttractor's Lic.'267177, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received'By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE A5 <br /> LESS / e <br /> PRORATION <br /> PLUS ZA <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received y POPIES <br /> Receipt No. Permit N . Issuance Date Mailed Delivered <br /> APPLICANT—RETURN O:��__ NVIRONMENTAL,HEALTH PERMIT/SERYIC€S 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />