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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r Non-Transferable, Revocable, and Suspends <br /> le ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application ;hereby made to carry on usiness in the jurisdictional area of the San Joaquin <br /> locfld District <br /> an Address <br /> aOwner��--�� �1�_ /.�.��.y Address . , <br /> �.Firm Partners, Addresses and TeleIfone Nu�m7be�rs�., ---- <br /> 5. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 7 <br /> Applicants Name (Print) f Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARENCE'S SEPTIC & SEWER SERVICE t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Ora * Stockton, Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites .Ph.463-3209 font t LIG.#267174 <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 , ^�H�' `SAL /;PL/ <br /> Owner AlA'G / .5.9t�'�'/ �L� Address &3 S to `> So ,V1V 1/Ti5' fF R ivE R QA'N/T <br /> ® SEPTIC TANK ❑ CESSPOOL IM LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 10 NEW 19 REPAIR ❑ OTHER Q1 <br /> S. ❑ 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 S <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. <br /> 11� <br /> I hereby certify that I have prepared this application and that the work will be done in acco ance with San Joaquin County <br /> ordinances, state laws,an le d regulations of the San Joaqui Local Health District. <br /> �.�� �� CLARENCE'S SEPTIC & SEWER SERVICE <br /> APPLICANT'S SIGNATURE X �—� 2633 , r 4L Stockton, Calif. 95205 <br /> C)(c.;, <br /> Ph.463.3209 Contractor's Lic.#261171 <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 /> BILLING REMITTANCE S <br /> BASE EXPLANATION' DATE DATE REMITTED AMOUNT DUE" CHECKED <br /> � ( AMOUNT <br /> FEE <0 (45 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ReCelveFbT Dale Receipt No. P01.11 NO. Issu e D le Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.NAZ AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />