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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION , <br /> (For Nan-Transferable, Revocable,and Suspenda6le) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE- <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) C L /1!C 4 AICIZ.F S,t 1Ot1e 74 •S,!5b1'45_X Address a 4�-g '70 1 `~0 S7 t- `r <br /> a Owner C L, ,P �/i!,~f SyC h�E-S Address � 5'c;, 0/q O Sits <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Lo o Emergency Telephone No. CIAa Business Telephone No. <br /> Contractor Licence No. 7 r <br /> 4 Applicants Name (Print) L L iV GL^ /��v S Title C- 4v 4a'77 Date - yF / <br /> Please check Applicable Category (1-7) and Fill in the Required Information Cf ARLtCE'S SEPTlC & SEWER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro _v Stockton, Calif. 95205 , <br /> For July 1, June 30, 19 Disposal Sites Ph. 403-3 )0 -.-. z - '- , <br /> Description(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 /> 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. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location j S �/� <br /> Owner R 6eAddress <br /> ig SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑-PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 06 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 d. <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 /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f that I have prepared this application and that the work will be done in accordant ith San Joaquin County <br /> I hereby certify p P <br /> ordinances, state laws, an s and regulations of the San Joaqui ocal Health District. <br /> APPLICANT'S SIGNATURE X ClAREf�CE'S SEPTIC & SEWER <br /> 263 SD. Oro J�L Stockt-on, C2;if. 952105 <br /> Ph-4'03-3209 Contractor's L.icA126717-4 <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 AIf <br /> �J <br /> LESS <br /> PRORATION <br /> PLUS ! 4 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S - <br /> Received b ate Receipt No. - Permit No.' -. Issuance to Mailed Qelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />