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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application is herebymade to car on business in the jurisdictional area of the San Joaquin Local Health District r <br />rn Bgsiness Name (DBA) ITONG ENGIN ERS INC. Address 4578 FRATIIER RIVER, SUITE A , <br />Q Owner C. CHANCE WONG Address STOCKTON, CA 95207 <br />Firm Partners, Addresses and Telephone Numbers <br />aBusiness Telephone No. 476-0011 Emergency Telephone No. <br />Contractor Licence No. MANCE 1PON PRES. 23 FEB. 87 <br />Applicants Name (Print) Title 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 <br />Description (Make/Yr., Color) <br />Serial No. <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />Disposal Sites <br />CAL. License No. <br />Gal., Weights & Measures No. <br />CAL. License Renewal No. <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored <br />3. ® PERCOLATION TEST <br />R.S. or R.C.E. Name C. CHANCE HONG R.S. or R.C.E. No. R.C.E. 14269 <br />Test Location 1480 N. WHITE LANE Test Date/Time <br />4. ❑ SANITATION PERMIT MS -86-3 <br />Job Address/Location <br />Owner <br />❑ SEPTIC TANK <br />❑ PERMANENT <br />❑ CESSPOOL <br />❑ TEMPORARY <br />Address <br />❑ LEACHING FIELD ❑ <br />❑ NEW ❑ <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />No. of Units <br />Disposal Site <br />SEEPAGE PIT ❑ PACKAGE PLANT <br />REPAIR ❑ OTHER <br />Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name <br />Plant Location <br />Plant Capacity <br />7. ❑ LAUNDRY For July 1, -June 30, 19 <br />No. Units Served <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 <br />ordinances, state laws, and <br />APPLICANT'S SIGNATURE X <br />Where Certified <br />ttion at let t e work will be done in accordance with San Joaquin County <br />of the n J Ginn Local Health District. <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 />BASE EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED) <br />AMOUNT <br />�F �'G-t/vliC. <br />��G. C.Y <br />FEE <br />'G'•Q� <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />