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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 SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 6 <br /> r Business Name (DBA) IeAlllfeA,E X-C-4� -a.A-0!V�Acid ressi <br /> aOwner Address A,6�7__ [ [�, <br /> z Firm Partners, Addresses and Tel p one Numbers <br /> 01 <br /> Q Business Telephone No. -� Emergency Telephone No. L <br /> ni Contractor Licence No. f <br /> Applicants Name Print .�(�.4—e pate <br /> PP (Print) <br /> — Title <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) CLARV10E'S SEPTIC & SEWER SERVICE <br /> For July 1, June 30, 19 Disposal Sites 263 SO. QrO Stool to Ca!II. 9520 <br /> Description(Make/Yr., Calor) •463-3209 Cc:ltractor'S I ic.:2F2671 <br /> Serial No, CAL'License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &`Measures No. <br /> Equipment Parking Address l <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. M <br /> Test Location Test pate/Time <br /> 4. SANITATION PERMIT t <br /> Job Address/Location ` <br /> Owner Address <br /> r� P <br /> ❑SEPTIC ANK El CESSPOOL JWLEACHING FIELD 4Y SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW: REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I <br /> Type Construction { Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) c I <br /> 6. ❑ PACKAGE TREATMENT PLANT FortJuly 1,:-June 30, 19 } <br /> Operator Name L Where Certified <br /> Plant Location 1 to <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 } I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> y <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 a regulations of the San Joaqui - ocal Health District. { <br /> CI-AREl4CE'S SEPTIC & SEWER SERVICE <br /> APPLICANT'S SIGNATURE X era J <br /> i <br /> Ph-463-3209 Ccrttracto,'s E_ic,#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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTEE AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE `1 S.po <br /> LESS w <br /> PRORATION <br /> PLUS *<�// GG <br /> PENALTY !�?? J ��11 <br /> OTHER a <br /> OTHER <br /> _ 9� <br /> 'Received by - Date - Receipt No Permit No. Issuance Date Mailed <br /> o ` `APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AYE.;P.O.Box 2009 5TOCKTON,CA 45201 <br /> Iz r. _ <br />