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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) $EPTAtyE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatio is ereby made to carry on__t1U.siness in the jurisdictional area of the San Joaquin Local Health District <br /> BusineIf <br /> ss DBA) Address G <br /> aOwnelt` '� Address Gee <br /> Firm Partners, Addresses and Telep one Numbers <br /> aBusiness Telephone No. — Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) Title '1 Date <br /> Please check Applicable Category (1-7)and Fill In the equired Information CLARERCE'S SEY71C & S&%,',; <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 2US So. C)s"0 } $tQC!CtOI}i Gaiii. 9 �i� <br /> For July 1, June 30, 19 Disposal Sites <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 Address ^+ <br /> A- <br /> 11 SEPTIC TANK 11 CESSPOOL LEACHING FIELD OSEE AGE PIT ❑ PACKAGE PI 15<1 ANT' <br /> ❑ TEMPORARY NEWREPAIR ❑ OTHER <br /> 5. 11 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 _ y <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. O <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> CLAREIVCc S SE>rI'1C & SEWER SERVICE <br /> 263 So. Oro * Stockton, Calif. 95205 <br /> Fh.463-3209 Contractor's Lic.#267177) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an d regulations of the San Joaquin Jeocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> L <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE +� <br /> LESS s L <br /> PRORATION <br /> PLUS r <br /> PENALTY S'1! <br /> OTHER <br /> N <br /> OTHER <br /> Received y at Receipt No. Permit No. Issuance Date Mai ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.aox • $,TOCKT� ON,CA 95201 <br />