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7z a tom. ., ''61'_ TO fign i ne Application. <br /> APPLICATION <br /> rte^ (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> �(DA) <br /> lica on is here made to carry on business in the Jurisdictional area of the San Joaquin Local Health District <br /> H Business Name ____ AddressOwner �101•7 _it t2<4n Address����/Le A��r <br /> 4 Firm Partners, Addresses and TelepK&ne Numbers <br /> a Business Telephone No. __,_ ______________ __-__ Emergency Telephone No. <br /> Contractor Licence No. _ - — <br /> a Applicants Name (Print) .4;aLA02zy � . �QSG/j T-— Title y//4fen17--'✓ Date 1l <br /> Please check check Applicable Category (1-7)and FIII 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 tJune 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. W) PERCOLATION TEST _ <br /> R-S. or R.C.E. Name , )&g-, ./i e .q„r-er R.C.E. No.^4G <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner . — -- - --- - - <br /> ❑ SEPI <br /> ❑ PERI DWAIN C. TOSCH - <br /> 1482 <br /> 5. ❑ C ELIZABETH P. TOSCH <br /> 1229 GOLDENOAK WAY 478-4606 <br /> Type Cc STOCKTON, CALIFORNIA 95209 v�L' 19,C� 90-108/1211 <br /> No of U <br /> s- ❑ P, PAD TO THE $(�I�,IGi <br /> Operator ORDER OF \ <br /> i <br /> Plant Lor DOLLARS -- <br /> Plant Cad � - -- - <br /> 7. ❑ Li UNION SAFE 7006 - --- <br /> SIZE: DEPOSIT BANK I <br /> ❑ 5555 N Perehing Av..Stockton.CA 95207 4 <br /> DRY <br /> - <br /> CSuch ;all notem lo an <br /> Cam„ employ yverse n <br /> ploy 'mit is issued.I shall <br /> rr Wuy urittty trial 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 thle S 1 Joaq n Local Health District. <br /> APPLICANT'S SIGNATURE X , C - Z _ <br /> s'. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY C3 PER UNIT PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT OUE CHECKED <br /> --- ---- — _ AMOUNT <br /> FEE -- <br /> LESS <br /> PRORATION - �.0 <br /> PLUS — <br /> PENALTY <br /> OTHER ---- -- <br /> OTHER -- - <br /> �sa�_ ��-3-� / __ _ •ysl�2. _ <br /> Received by Date fleceipt No. Permit No. IaauanCe—Date— <br /> APPLICANT-RETUR <br /> ateAPPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _- —. <br />