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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 /> F Business Name (DBA) Address z <br /> a Owner ddress <br /> Firm Partners, Addresses and Telephone Nu ers <br /> aBusiness Telephone No. Emergency Telephone No. I <br /> Contractor Licence No. `l <br /> Applicants Name (Print) C �� T )`�P � R Date <br /> �z-�� � - Title <br /> Please check Applicable Category(1-7) and Fill in the Required Information r "^ St';;`�R SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 203 So. 0,o i� Stockton, Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites ph,463-3Mt flntraGLor's LiC J267-17J <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. X SANITATION PERMIT <br /> Job Addres ocation <br /> Owner oe <br /> Address + <br /> ❑ SEPTIC TANK CESS OL LEACHING FIELD A'SEEPAGE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ 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 /> CLARENCE'S SEPT!C & SEWER SERVICE <br /> 263 So. Oro ,s Stockton, Calif. 95205 <br /> Ph.463-3209 Col tractor's Lic.-A26AZ , <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County a <br /> ordinances, state laws, and r regulations of the SaD Joaqu.�q Local Health District. _ `Fn�;,Ce <br /> ­`!� -.3i <br /> APPLICANT'S SIGNATURE X <br /> Ph.4c 3-J269 Cul-,'.F. i::r n.%6717_1 <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> R AMOUNT <br /> FEE � y�`~U -y, <br /> LESS `tom <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> lv I GI I 30 C <br /> Received by pate t Receipt No. it No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />