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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> f (For Non-Transferable, Revocable, and Suspendable) SEEPAGE <br /> y ENVIRONMENTAL HEALTH PERMIT <br /> a LIQUID WASTE <br /> Appl icatio is reby made to carry on business in the jurisdictional area of the San Joaquin Local Health District � <br /> N Business BA} Address �� (�,/,�/s 7 <br /> z Owner Address <br /> a <br /> I <br /> a Firm Partners, Addresses and T one Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> .J Contractor Licence No. <br /> a Applicants Name (Print) �i!/IC�P' e Title �0��* Date <br /> L Please check Applicable Category (1-7)and Fill in the Required Information CLAF.>IdCE'S SEPTIC & S Calif.f 95205 <br /> SERVICE <br /> 263 So. Oro � Stockton, Cal <br /> 1. 11PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> � <br /> For July 1, June 30, 19 Disposal Sites. Ph.X453-3209 Contractor's L.C. 26X77 <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 /> L For July 1, - June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> a 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/Lg.cation '�a A`leL <br /> Owner 1 // c Y Address r 6 'a _ To�r S /' i e .i� 2/0 A_ <br /> ® SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0 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 /> l Plant Capacity ( No. Units Served <br /> i. 7. 11 LAUNDRY For July 1, -June 30� 19 . <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ` 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f Y r <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, a the nd regulations of the San Joaqui Local Health District.CLARETICE'S SEPTIC & SEWER SERVICE <br /> 263 So. Oro Stockton, Caii(. 952D5 <br /> APPLICANT'S SIGNATURE X Ph.46;;_J209 Contractors IC. L <br /> 0� <br /> L FOR DEPARTMENT USE ONLY <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ 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 ` <br /> �FEE <br /> RATION <br /> [ PLUS <br /> € PENALTY <br /> [ OTHER <br /> OTHER <br /> � � 1 �� Cn <br /> ar3 ti <br /> Received by Date I Receipt No. PermibNo. Issuanc ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA LT AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> - S <br />