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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 SEP7AGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name {DBA) 7- S--w�� Address 19 ra 3 S c c - cS'Tn c- <br /> a Owner C L 'q RE<�� `s y �'9 h�S_ Address 3 .S d Ro ,1,T— <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 6 0.3 .2- CP Emergency Telephone No. -�- <br /> Contractor Licence No. 7/ 7 i <br /> L Applicants Name (Print) ��/� �' CGE G G as Title (f a e7 7- Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLAPE.4CE'S SEPTIC +°C SEWER SERVICE <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 2633o. 0,''0 SocL"h0 Cr`i. 9�205 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) J <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 r _ <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/Location � A G 1"?,k .S 6-Z O ''✓ <br /> Owner 1AI IV r Address ZS /9 51 h'1i'Z 4-_L,4 ,R 57— �_ ,S G� per✓ <br /> ® SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 <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 /> 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, ul and regulations of he San Joaquin cal Health District. <br /> APPLICANT'S SIGNATURE X CLARENCE'S SEPTIC & SEWER SERVICE <br /> 263 So. Oro z, Stockton, Calif. 95205 <br /> Ph. 463-3209 CDiVr�lctcr's Lic.#267177 <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 $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4 <br /> LESS <br /> PRORATION �7 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I Date Receipt 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 2009 STOCKTON,CA 95201 <br />