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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> �i (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> II ENVIRONMENTAL HEALTH PERMIT . <br /> LIQUID WASTE <br /> Application is hereby made to carry on iness in the jurisdictional area of the San Joaquin Local Health District <br /> Business N�e ( A) Address rI .Tor 011106"AplP ' a <br /> a Owner - Address <br /> J Firm Partners, Addresses and Telephon Numbers <br /> aBusiness Telephone No. y" Q Emergency Telephone No, <br /> J Contractor Licence No. rX <br /> L Applicants Name (Print) Title t?94,4z: Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information CLARENCE'S SEP'EIC & SEV'dER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oto-* Stockton,Calif. 95205 � <br /> ` For July 1, June 30, 19 Disposal Sites r"� <br /> II Description (Make/Yr., Color) <br /> Serial No. CAL. License No. -" CAL. License Renewal No. <br /> Capacity Gat., 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 1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. N, <br /> Test Location } Test Date/Time <br /> s 4. A SANITATION PERMIT - <br /> Job Address/Location <br /> f I � <br /> Owner Address <br /> ❑ SEPTiC TANK ❑ CESSPOOL EACHING FIELD SEEPAGE PIT ❑ PACK'A4 PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR -`❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> k 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, ElLAUNDRY For Juiy 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 /> y <br /> > I 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, d regulations of the an Joaq.in Local Health District. <br /> APPLICANT'S SIGNATURE X CLwREtvCE'S SEF(i[; <br /> an �tUVEIt 3tl<,i' <br /> N 263 So. Oro -11 Stockton, Calif. 95205 <br /> RPh.463-3209 Contractor's Lic.#267177 <br /> h! FOR DEPARTMENT USE ONLY , <br /> Fee IS Due: ❑ ANNUALLY c ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1 &Received By January 31 v ❑ Julyt &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE/ REMITTED AMOUNT <br /> FEE r <br /> I "77'VVV �-•'c <br /> r. LESS <br /> PRORATION <br /> l1 <br /> PLUS � <br /> PENALTY <br /> ' OTHER 7__ / <br /> OTHER h <br /> a'5AA M Q <br /> Received by Date Receipt No. Permit No. I a , Mailed .0, `Delivered `._. <br /> APPLICA T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELCAVE.,AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />