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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) SEPTAL <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 /> ,Business Name (DBA) Address <br /> a Owner Robert & Vickie Van RLiten Address 361 E Harney Lane T ndi , CA 95940 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 334-1095 Emergency Telephone No. <br /> Contractor Licence No. Dillon Engineering <br /> Applicants Name (Print) ni 11 on Enginaaring Title Civil Engineer Date 4-11-99 <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. I <br /> Equipment Parking Address 0C <br /> 2. 11PUMPER YARD � <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored n ) <br /> No. of Chemical Toilets Stored 7' <br /> 3. ® PERCOLATION TEST — S <br /> R.S. or R.C.E. Name Cecil Dillon R.S. or R.C.E. No. 95,915 <br /> Test Location 361 E• Narnl-yT aane, Lodi, CA Test Date/Time 4-11-89 / 8.0Oa m — 1�•09P.m <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address rJ) <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) f� <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 /> F <br /> I hereby certify that I have pr _ red this ap 'cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r At regul s 5�� aiquin 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> is <br /> FEE ®i� �•� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Iky <br /> Received by Date Receipt No. Pe it No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br /> i <br />