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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. loo <br /> APPLICATION <br /> r (Far Nan-Transferable, Revocable, and Suspendable), <br /> Q 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 /> Business Name(DBA) 44Xee7i S. uJ Address -` C, 3 So. CM?a <br /> Owner 4? ' Address !" <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 1�� � / Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) « e � S Title ._. Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information CLARENCE'S SEPTIC & SEWER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) 263 So. Oro * Stockton, Calif. 95205 c <br /> ' For July 1, June 30, 19 Disposal Sites Ph $65_g9fl9—t,;nnt Pt9f'S 196 49r7l <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 /> S, ❑ PERCOLATION TEST <br /> ' B.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 Ode Lo sire <br /> ' Owner eu Address S7466 , 7L-ff <br /> ❑ SEPTIC TANK 11 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT �� �e4c/11 <br /> 13 PERMANENT ❑ TEMPORARY 11NEW REPAIR ❑ OTHER ��� .2-S-�X �aO.) <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ' Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> S. ❑ 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, 19tnl�fjl;HI ,y o <br /> SIZE: ® Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. €, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ¢. <br /> ST <br /> IP✓ #�iotiMn <br /> /�a'` a4wW <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 r s an agulations of tha San Jc qu;n Lac Health District. <br /> CLA?Ei ^E'S SEPTIC & S—WER SERVICE <br /> APPLICANT'S SIGNATURE X ro �iCCltii ?, L3IIf. 95'35 <br /> Nh -X3..',2fI; <br /> ' FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNOT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 37 <br /> REMIT <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION i <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ' LESS <br /> PRORATION 'V <br /> PLUS <br /> PENALTY <br /> OTHER + <br /> ' OTHER <br /> zj <br /> Received by ate Receipi No. Permit No. Issuance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2609 STOCKTON,CA 95201 <br />