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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Tran.,4rabie,�tevocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) IVONG ENGINEERS, INC. Address 4578 PRATHER RIVER DR. "A <br /> a <br /> Owner Address STOCKTON CA 95219 <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. 476'0011 Emergency Telephone No. <br /> 4 <br /> Contractor Licence No. <br /> L Applicants Name (Print) G. CHANCE WONG Title PRE• Date $-14— <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. 19 PERCOLATION TEST <br /> R.S. or R.C.E. Name C. CHANCE WONG R.S. or R.C.E. No. R.C.E. 14269 <br /> Test Location 10452 S. AIRPORT WAY Test Date/Time <br /> 4. ❑ SANITATION PERMIT LA-91-2 <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 <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 /> I hereby certify that I have prepared this ap lication an t he work will be done in accordance with San Joaquin Co my <br /> ordinances, state laws, and r d I ns of the J quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> /* cv—/ 67,-2 / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receivec By July 31 <br /> MIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CH CKED <br /> DATE DATE REMITTED <br /> A OUNT <br /> FEE Q�p <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t �}- <br /> i /I.S/f t y-'T 1"7 °I <br /> Received 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 />