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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) SE PTAGE ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OFBusiness Name (DBA) L Lc'lV �'S i e- Address <br /> aOwner /Q �� Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. 2, v <br /> Contractor Licence No. <br /> � <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information CLARET` E'S SEPIIC & Sbf-TER SERVILE 04 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro 4 Stockton, Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites 'Ph.433.3209 <br /> p(I r <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.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ ocation I <br /> Owner v S/ Address 7""� S <br /> ® SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY IN NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 WJ <br /> Type Construction Disposal Site C.) <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. 4AQIsl1 <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 rule nd regulations of the San'Joaquin L al Health District. <br /> APPLICANT'S SIGNATURE X CLARENCE'S SEPI, <br /> & SE JER SERUIGE <br /> ?63 So. Oro * Stockton, Calif. 95205 <br /> Ph.463-3209 Contractor's Lic.J267174 <br /> FOR DEPARTMENT USE ONLY <br /> .Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El "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 I <br /> k O <br /> FEE 4y D <br /> I. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> e <br />"f OTHER <br /> OTHER <br /> rn 3 9y <br /> Received by - I Date Receipt No Permit No. Issuance Date M iled , Delivered... <br /> I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />