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r •• =W01819C. -F oiaPe 76 'gn I ne Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE t <br /> Applica on is here made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DPA) _ Address.__ <br /> Owner � — - - Address _11s7. <br /> 3 firm Partners, Addresses and Telep"one Numbers _ _ �` j <br /> aBusiness Telephone No _ Emergency Telephone No. <br /> Contractor Licence No. _ - -—— <br /> �-Applicants Name (Print) Lem/r7 G /OS G-- Title C/✓��Ei�e'i�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. 0 PERCOLATION TEST <br /> R.S. or R.C.E. Name _�JS li L• f� G /j _tea R.C.E. No./Y/G y� <br /> Test Location Test DateTTime 11` y'5?1 -V79- <br /> 4. <br /> V <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _ — ------- <br /> ❑ SEPI <br /> ❑ PERI DWAIN C. TOSCH 1482 <br /> 5. ❑ C �\ ELIZABETH P. TOSCH - <br /> 1229 GOLDENOAK WAY 478 4606 <br /> Type Ca STOCKTON, CALIFORNIA 95209 cC'• ._19L� 90-108/1211 <br /> No of U --- <br /> 6. ❑ P, PAY TO THE �'Wj .G�7/ J $ <br /> Operator ORDER OF /T - -_ <br /> Plant Lo j . � ©�dU DOLLAR S <br /> Plant Cal ^ - --- <br /> 7. ❑ Li UNION SAFE 7006 - <br /> SIZE: DEPOSIT BANK vv�\11 <br /> ❑ <br /> DRV 5555 N Nrehing Ave.Stockton.CA 95207 <br /> C / i <br /> Home <br /> in SUCK <br /> con" gall not employ any person <br /> emloy -Mit is issued.I shall <br /> --y uatttty tear I nave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an#rules and regulations of thhe S Jq 'n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 d Received By Jury 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE . DATE REMITTED AMOUNT DUE CHECKED <br /> — ----- ---- - AMOUNT <br /> FEE ��� /lJ li � - <br /> LESS V t oW <br /> PRORATION r <br /> PLUS --- - - <br /> PENALTY <br /> OTHER <br /> OTHER -- <br /> Received ty ---Date -- Reeeipt No. --Permit No ---Isauanee Date Mailed Delivered - <br /> - APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Bort 2009 STOCKTON,CA 95201 —--- <br />