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APPLICATION yrf L �9 <br /> lokiiiv-or Non-Transferable, Revocable, and Suspendabflr� l: 30 SEPTAL--E <br /> ENVIRONMENTAL HEALTH PERMIT V C—L-L <br /> LIQUID WASTE <br /> Application is hereby made to arty on business in the jurisdictional area of the San oaquin Local Health District o <br /> 0 Business Name (DBA) ftUs ifl� p/oZ1A _ Address ELM -ST, L-J4D1,.r1& 752�Gr <br /> i Owner TERRY P/,&7.7ZA _ Address ST- <br /> 0- Firm Partners, Addresses and Tele hone Numbers __ <br /> a. Business Telephone No. Emergency Telephone No. 3j:A -ea 114 <br /> Contractor Licence No. <br /> a Applicants Name (Print) t ERRY PIAZZA _ __ __ Title 4,' . E __ —__ 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. a PERCOLATION TEST e! <br /> R.S.O(&-MNMa- ! R.S. or Com, No. <br /> Test Location 11.((__YY _�-V�VIS �, _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location -_ <br /> Owner _ Address - - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT _ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER I <br /> S. ❑ 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 <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 /> goltl. ", 5 p4 s S <br /> I hereby certify that I have prepared this al?iAcation and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rul i and riagplalions of the San Joaquin Local Health District. <br /> r <br /> APPLICANT'S SIGNATURE X - <br /> 10, 71 <br /> 2 TE's% NDI.LS R69CE L 1 F,�r✓l a j►�11�R. <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 July 31 <br /> REMIT <br /> BILLING REMITTANCE $SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AM/AUNT <br /> FEE ald <br /> LESS <br /> PRORATIONPLU _ <br /> PENALTv -- — — -- - - — <br /> OTHER } <br /> OTHER <br /> -";!c edRy -�- D-�L__L� Recaip P � -_ Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O-Box 2009 STOCKTON,CA 95201 <br />