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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> Z3 D 4 St , 4-IA � ' LIQUID WASTE ;L`�j — v'70 / <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DE3 Mizuno Farms , Inc. Address 29050 Ahern Road Tracy, 95376 <br /> Owner Rayman a Juno e a Address 29050 Ahern Rd. Trac 537 <br /> di z Corporation209/d35-515V <br /> J Firm Partners, Addresses anj(�hle� n Nt b� s <br /> 0. Business Telephone No. "" y/ 1 - Emergency Telephone No. 209105 X59 <br /> a Contractor Licence No. $e <br /> Applicants Name{Print) clan 1Zuno Title mfr' Date 29 <br /> Please check Applicable Category (1-7) and Fill in the Required Information O <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 R.C.E. Name R.S. or R.C.E. No. <br /> Test location r est te/ i e <br /> 4. K3 SANITATION PER T ! � � �upp <br /> anteca Ranch Eas si e o a parageking shed. a�dbunkhousEo <br /> Job Address/Locatio 4 <br /> Owner Raymond T. MiZurio, etai Address 29050 Ahern Road Tracy, CA 9537 a <br /> *SEPTIC TANK CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT §UTEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction N&IJ Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> h <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. n <br /> L3 DRY CLEANING, Chemicals Used/Amount/Mo. -16 <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, an les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 46� J <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ass <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> !OTHER <br /> Z 2g 8d 8 <br /> R ceive ey Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 9520® <br />