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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 <br /> SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) Address _rf �v ' <br /> z Owner Address' <br /> a - <br /> a Firm Partners, Addresses and Telepho a Numbers <br /> aBusiness Telephone No. «� c Emergency Telephone No. <br /> Contractor Licence No. I ' <br /> Applicants Name (Print) "vef ,CT z Title — Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information CLARENCE'S SEPTIC & SBNER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro 4L Stecidon, Ca€if. 95205 t <br /> For July 1, June 30, 19 Disposal SitesPh.463,3209 I <br /> Description(Make/Yr., Color) �u t <br /> Serial No. CAL, License No. CAL. License Renewal No. q <br /> Capacity Gal.,Weights &Measures No. I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 I <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 r <br /> Job Address/ cation <br /> Owner Address �- e <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY r NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 1 <br /> Type Construction Disposal Sitej <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. 'F <br /> 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_nd-r I d regulations of the San Joaquin Local Health Distict. <br /> 61PAEKE'S SEPTIC & SEVJER SER'•VICE <br /> APPLICANT'S SIGNATURE X <br /> W463-3209 Cont.actor's Lic.#2671774 <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juky 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESSr/ �f-fK <br /> PRORATION f/X CJ <br /> PLUS w <br /> PENALTY <br /> OTHER <br /> OTHER k <br /> V <br /> Received by I Date Receipt No, Permit No Issuance a e Maiied Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITIsERYICEs 1661 E.HAZELTON .,P.O.Box 2009 STOCKTON,CA 95201 <br /> F <br />