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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> tel. S APPLICATION '4# $959 PNENNaF, <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to arty on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) PJ& g� <br /> I -A -Address_2�22.w.-j ISA fir. L-im, cA. 95240 <br /> a Owner'TERKY P j/]ZZA Address 32� m F-t- 1 S7 LOy1� 9�?�-Q <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. ���/�//� Emergency Telephone No. <br /> Contractor Licence No. <br /> q Applicants Name (Print) _TEKfkY P/,62�7,4 Title C r=- <br /> — 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. 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 .C.E Name 'TARRY 9/4ZZA R.S. order No. (� <br /> Test Location _6o rJ , �J pEL TIER RD4 Test Date/Time <br /> 4. ❑ SANITATION PERMIT LS�a�QG, �yJ ,.i <br /> Job Address/Location ___ � .5—xa� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT Iiiz- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 W <br /> Type Construction Disposal Site <br /> No of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. 0 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 /> Home ownerorlicensedagant'a signeturecertmesthet91towirrg:"I rertlfyqShAf in the p erfor n?nco of thev.ork fanahich this permit is issued.I shall net employ any person <br /> in such manner as to became s�5iec1 t0.%,jrkina;-s car peamilkyn Iawz of Califc rti.: <br /> Contractor's hiring or sub-contracting oignoture Certifiers 11m taitowing; -1 caftify that in the performance of the work for which this permit is Issued.I shall <br /> employ persons subject to workman's compensation laws of Catifornia.' <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations -than Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 4e <br /> 2 -a-r--5T s — EMC—L!: �- <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 J ly 3f <br /> REMIT <br /> BASE E;XPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE /��L, _ :`�f" 0 <br /> — <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> R eived by Date 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 />