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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) 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 /> ,FBusiness Name (DBA) ARLP JS �YfUC Address �� ( <br /> aOwner- x: Address T <br /> Firm Partners,Addresses an�dTelle hocne Numbers <br /> CL l� � ne <br /> Business Telephone No. �2017 Emergency Telephone No.- <br /> Contractor Licence No. Z�� �...`' <br /> L Applicants Name (Print)�7 p,, X?1__ y fit_ r Title Date - <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License NO. T 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 r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST - -- -- <br /> r. r <br /> R.S. or R.C.E. Name r F R.S.or R.C.E. No. <br /> Tt9ocation Test Date/Time <br /> 4. SANITATION PERMIT I <br /> Job Address/Location 1 E!�7 - •I -Q���12 - Ids_y <br /> O ner f-) � �Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD E PIT ❑ PACKAGE PLANT �� <br /> PERMANENT ❑ TEMPORARY ❑ NEW r REPAIR tr0 OTHER 2~ f D <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 j 14 <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 /> Flame owneror ticeresed-agent'a eidnature nettifiet tho ft.inwing,1 certify that In'the f erformOnCsOf the wark ferWhI0 thllt 90mif 16 l@ md,I AM not flf i pl oV @ifs l�@F@@fl <br /> in such manner as to become subject to workmaTfb <br /> Emnlaector's hiring pr subrantractirtg 51r3fya.li i6 c�rtifi r �t,-: 'c::ttyvi€, 'I '11-1:+s+yit4;tl1:itC iln;'iC;<'i,fl;rc :f°?.4',+3r16 iAf WhiCC)f thll Pprf?#if l6 if��llFti,l 13 1 11 <br /> P y Persong subject to%vorkmari s comPansaiinr .ar, 1:;c,..,,,.' i <br /> I hereby certify that I h e prepared this application and that he work will be done in accordance with San Joaquin County <br /> ordinances, state laws and regulatio of the S quin Lo eaft District. <br /> APPLICANT'S SIGNATURE X 1 <br /> `d.�""" tel✓ ll' G <br /> i <br /> FOR DEPARTMENT USE ONLY /� <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive January 31 [3 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> -.DATE DATE i REMITTED AMOUNT <br /> J r p <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 7 <br /> OTHER <br /> Received by Date r Receipt No. Permit 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 />