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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION P LY -*CIO .106 <br /> i —4- 1 (For Non-Transferable, Revocable, and Suspendable) SEPTAC-E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to c rry on business in the jurisdictional area of the San Joaquin Local Health District <br /> � <br /> Business Name (DBA) ()Me5,Nf .W g P/AZZA Address SZ3 W. El_k . St i. 90 I ee 95_5Z4 <br /> T <br /> Owner ' ��ZfZY p1,NZZA Address W. EL ST L-9921 C-A. 95240 <br /> Firm Partners, Addresses and Tele hone Numbers <br /> Business Telephone No. 3� "�OGJ Emergency Telephone No. 36O Co I q4- <br /> Contractor Licence No. <br /> Applicants Name (Print) TERRY PIAZZA Title G.T__ • Date t ` 3-0 9 <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. J4 PERCOLATION TEST q& <br /> R.S. or .C' E Name -TERR .C.E <br /> Y F'/DZZA R.S. or No. I <br /> _ <br /> Test Location "2.01 w JAI-Lm-7 1ZD dGLIAD Gest Date/Time ' 1— It t 342 A64 <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 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site PA r A Piur <br /> No of Units Equipment Storage/Cleaning Location(s) HIEn .-"._ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r C 0 _ <br /> Operator Name Where Certified 4 199l <br /> Punt Location _ _ __ p ^ �i.AQUIN nzJ <br /> Plant Capacity No. Units Served - <br /> EiVVrR Nht► � LE�VrTNr-� <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 `ACTH DIVi�;Op.: <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or fieensed agent's signxltore t ertifiesthe following:"I certify that in the performance of the work for which this permit is issued.I shall not employ any person <br /> in such manner as to become subject to Yorkr;ai'c G::r:3LtES l;'l.i!a vs Callfrr-:.e <br /> Contractor's hiring or sub-cortam rg ane+.are cert::'." -4ip •iullow.ng: 1 certity that in the performance of the work for which this permit is issued.I shall <br /> employ persons subject to wu kmans compu,i3atiun iawb of Ca,iiatnia." <br /> I hereby certify that I have prepared this application and that the ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joa Local Healt istric . <br /> APPLICANT'S SIGNATURE X <br /> "7S`► - PoP.G L 11 Z- <br /> 1-moi 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 July 31 <br /> BREMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE MITTED AMOUNT DUE CHECKED <br /> T / AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> AV v Z <br /> Rec iv 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 />