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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 /> r ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r LIQUID WASTE . <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District ) <br /> ' r Business Name (DBA) f� � e, 5' :57Cj7`'!lf .4,ITC-6a 1?,! _ Address _7 <br /> a Owner C !��/�� AICZ6;i1�---y- Address- �. G�1 ��')'`/�/� ✓ BOJ <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> ILBusiness Telephone No. - Emergency Telephone No. ' <br /> Contractor Licence No. a�a� ` <br /> Applicants Name (Print) C�iCe /���� cT �/ � r Title ' <br /> -ItL �� e� � / <br /> Date z� " <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARE"ACE'S SEPTNT & S-EVVER SERVICE _ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro 55205 <br /> For July 1, - June 30, 19 Disposal Sites Ph,4C}-22u <br /> Description(Make/Yr., Color) , <br /> i Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal„ Weights & Measures No. Jr <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> III No. of Chemical Toilets Stored <br /> k <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. 9 SANITATION PERMIT / da <br /> Job Addres /Location _7 <br /> Owner �G�,Af A'"' Address ,4 46 IV'e/e � <br /> X SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ASSEEPAGEPIT ❑ PACKAGE PLANT <br /> JR PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER pQ <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 /> 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 ru!a egulations of the San Joaqui Local HealthI <br /> M F�dCPS SEPTIC & SEkrr'LR SERVICE <br /> APPLICANT'S SIGNATURE X '� '263 <br /> Ph 463-:229 Cai,{r;ctor'sL67177r <br /> l FOR DEPARTMENT USE ONLY <br />( fee Is Due: ❑ ANNUALLY Cl PER UNIT T91 PER SITE' ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> NG EMIT ANCE $ REMIT , <br /> BASE EXPLANATION DATE E REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS (� <br /> PENALTY t <br /> i <br /> OTHER I <br /> OTHER � <br /> Received by Date # Receipt No, Permit No. Iss nce D to MailedDelIver . <br /> F APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERYEGES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 95201 <br /> q � <br />