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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r '� �" �'• (For Non-Transferable, Revocable, and Suspendable) SEPjAGI <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 4 y L4 4 4 CA 114—?r- I LIQUID WASTE <br /> u <br /> Applicatio5g Applicationhereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) R <br /> address . <br /> aOwner Address <br /> Firm Partners, Addresses an�Teleone umbers <br /> aBusiness Telephone Na. 20 Emergency Telephone No. <br /> Contractor Licence No. T � � <br /> LApplicants Name (Print) Title Q' �1�� . 0 Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information CLARENCE'S SEPTIC & SEVVER SERV,IB <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. O.ro SEod"hn, Cali#. 95205 14 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. GAL. 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 1 <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. iR SANITATION PERMIT <br /> Job Addre cation <br /> Owner Addtrw�v \ <br /> ❑ SEPTiG TANK ❑ CESSPOOL LEACH%G FIELD res SEEPAGE PIT ❑ PACKAG PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW `REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> i Operator Name <br /> k Plant Location <br /> C No. Units Served <br /> Plant Capacity <br /> a <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/AmounVMo. <br /> i <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 s regulations of the San Joaquin Loc Health District. <br /> pSEPTIC <br /> APPLICANT'S SIGNATURE X <br /> 253 So. Oro CP4. 95205 <br /> �. <br /> Ph.463-3209 Lsc.x'267173, <br /> L <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION t� <br /> f PLUS <br /> F PENALTY <br /> OTHER <br /> t OTHER <br /> I 80S � p <br /> Received by at Receipt No. Permit No. issu In Date Mailed Delive d <br /> APPLICANT;RETUAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Box 2009 STD TON,G 95201 <br />