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npNucauuns rrm oarrvck 1.r rrnrn.7uorluue'v rrvpeny a.urnptell:v. or sure oryn r lien}7Nn�uuvn. <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 <br /> rn Business Name (DBA) S f Address__�2<; 3 S'p L7iQCY Sof�,�� <br /> Owner Address �ww e <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. �.r Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name,(Print) Title �� Date 02-.Z 3 -e2- I <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARENCE'S SEPTIC & SEWER SERVICE S <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 S0. Oro * Stcckton, Calif. 95205 c <br /> FFor July 1, June 30, 19 Disposal Sites Ph._463-3709 GOnt-cle.r's Li.E #26-71-]-7 <br /> IDescription(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 /> July 1, June 30, 19 <br /> ,For <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 I <br /> 4. XSANlTATION PERMIT <br /> Job Address/Location ae C /� Gl <br /> Owner-- �� Sfn Ze 6496e_R .-- Address tJ y r <br /> �❑ SEPTIC TANK ❑ CESSPOOL )irLEACHiNG FIELD WSEEPAGE PIT ❑ PACKAGE PLANT 4 <br /> ❑ PERMANENT' ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER �dCr f ,CeAcf� o <br /> [5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 l-YL-R r /�I �s�fx33<J <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) __ 1 <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified n <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 s� <br /> 'SIZE: 13 Less Than 1,000 Sq. Ft., El More Than 1,000 5q. Ft. �_:��,.;���� • .� � s �. <br /> 13DRY CLEANING,Chemicals Used/Amount/Mo. ' " <br /> A"�ile <br /> 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 rr !aan egulations of the San Jo quip Lac Health District- <br /> APPLICANT'S SIGNATURE X <br /> SEPTIC & " riER SERVICE <br /> J. <br /> R <br /> --f pro u . .r;? Calif. 95270577 <br /> ,rr:"(:_o1r's Li%.''!N717Z <br /> •Lr <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:'❑ ANNUALLY - ❑ PER UNIT - I—] PER SITE 11 EACH <br /> January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> I <br /> ti FEE � I <br /> LESS <br /> PRORATION V <br /> i <br /> PLUS i <br /> 10 <br /> PENALTY I <br /> 1j <br /> t. OTHER I <br /> i <br /> i <br /> OTHER <br /> I <br /> I <br /> Received by Date I ' Receipt No, Permit No. I Issuance Di!!__. Mailed Delivered <br /> APPLICANT,—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 IF <br />