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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - ' <br /> (For Non-Transferable, Revocable, and Suspertdable) <br /> .�s,.4. ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAG r <br /> -- LIQUID WASTE 173 Z;�V <br />'I Application isereby made to carry on business in the jurisdictional area of the San Joaquin Loc Health District I11 h „ <br /> Business Name (DBA) Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Tele p one Numbers <br /> CIL <br /> Business Telephone No. .Z- Emergency Telephone No. <br /> Contractor Licence No, <br /> L Applicants Name (Print) "'e L Title i Date ET <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARE[�ICFS SCPTiC a &,''Y R SCRViCE l <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. a-o 4 Stockton, Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites ic,f267 TZ iM <br /> Description(Make/Yr., Color) <br /> • e� i <br /> Serial No. CAL. License No. CAL. License Renewal No. , <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored C3. <br /> No. of Chemical Toilets Stored p <br /> 3. ❑ PERCOLATION TEST d <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. II <br /> Test Location Test Date/Time :E (} <br /> 4. SANITATION PERMIT 00 oL 0 h�-OY/v�Y1f�0u�/t <br /> �OL <br /> Job Address/Loc ion + - ✓ o ':�, <br /> t <br /> Owner Address �l <br /> SEPTIC TANK ❑ CESSPOOL 'LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT �p 1 <br /> PERMANENT ❑ TEMPORARY ZNEW ❑ REPAIR ❑ OTHER -- ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> d <br /> Type Construction Disposal Site q I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served i. <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 C ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I .have prepared this application and that the work will be done in accordance with San Joaquin County �M <br /> ordinances, state laws, M2Z-t_'nd regulations of the San Joa �nLocal Health District. a <br /> it <br /> APPLICANT'S SIGNATURE X CL.4°cll;L.`S S_I'i iC J'='�liR SLR'riLE <br /> 26-'13 SD. Ilio �v" 'iCC��Cli~r Calif. 95205 <br /> ' Ff'. .1G 3_'2019 Cc,Iiiracioz s I.;V. <br /> h <br /> FOR DEPARTMENT USE ONLY <br /> id <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 it <br /> BASE EXPLANATION AMOUNT DUE CHECKED! <br /> QATE, .h DATE REMITTED AMOUNT( <br /> FEE Ak O ff <br /> LESS <br /> PRORATION �I <br /> PLUS <br /> PENALTY <br /> OTHER '~A I✓ II <br /> OTHER ------------ <br /> /rn <br /> Received byD to Receipt No. Permit No. I Issuance Date Me Delivered <br /> 'APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., ox 2009 STOCKTON,CA 95201' <br /> J <br />