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-•rr-.�_•.�•.� ••... -_ _______ ...._ __ ....-.__ — I _ _ I „ _ <br /> APPLICATION " <br /> ' (For Non-Transferable, Revocable, and Suspenda-we) SEPT/' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> F:•-mss' LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the an Joaquin Local Health District <br /> Business Name (DBA) ON JbAE- �G4 j 4 F'&-2A__ Address ;5 W r--Lm 4 <br /> owner—TERRY P/OZZA ____ Address L-L I-11 ST- L.W1a—f�--q5 Z4A <br /> u Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No, 10 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) 11"?MY p/hZZA ------- Title G•I=„ 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 Renswal 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 - -No o Chemical Toilets Stored - -- <br /> 3. PL/tTfl©N TEST (Q� <br /> R S.orCC�Name _ R.S. o No. <br /> Test Location - r Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ ,� / 7� /tel <br /> Job Address/Location <br /> Owner Address _ - — <br /> ❑ SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR r ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30. 19 <br /> Type Construction Disposal Site <br /> No.of Units _ - --- Equipment Storage/Cleaning Locations) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30. 19 <br /> Operator Narins 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 /> I hereby certify that I have lication and th a w60 will be done in accordance with San Joaquin County <br /> ordinances. state laws. and rules a� lations of the J4aQutfflocal Health District. <br /> APPLICANT'S SIGNATURE X - <br /> -�5 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July 1 d Reeelved By July 31 <br /> - - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t� p DCAATEp DATE ..fGfR�1EQM1 Ep AMOUNT_ <br /> FEE `' , - <br /> LESS <br /> PRORATION _ — --- - — <br /> PLUS - <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Recel by Date yu� l ce pt No. Permit No Isauence Date Mailed Delivered - <br /> APPLICANT-RETURN ALL COPIES TO: CWVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 -- <br />