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Apply.. , I „ill Be t'lu:, .d Wllen subnutteu I'toperly Uumplelea. tie sur o sign I Ile Hppncauon. <br /> ` APPLICATION <br /> Non-Transferable, Revocable, and Suspendab SEPT, E <br /> ` ENVIRONMENTAL HEALTH PERMIT \G�, <br /> LIQUID WASTE s <br /> FApplication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Di�'Irict I�! <br /> Business Name (DBA) Address <br /> I Owner_Robert & Vi_k1e_Van__RUiten_ _ Address 361 R_ Un r., _ QOn 4_ <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. —334-1095 Emergency Telephone No. E,'�iVll? a A <br /> Contractor Licence No. Dillon En�ineel-ln PE,?A41G7 �IAL P <br /> <�L / <br /> a -- — <br /> L Applicants Name (Print) Dillon F.n- e— rin$ TitleCivil Engineer Date—4_j"9 ` <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. ® PERCOLATION TEST <br /> R.S. or R.C.E. Name Cecil Dillon R.S. or R.C.E. No. 25_rA 5 <br /> Test Location .-361 F.. HarnpV Tane,j,od1l, CA Test Date/Time 4-11-89 1 8- Oa-m,-17:00 <br /> 4. <br /> aym,--12:Qp4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR at ❑ 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 pr Bred th&apHcation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r e Ro, euin Local Health District. <br /> APPLICANT'S SIGNATURE X '' <br /> 1 ! 4 <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 /> BASE EXPLANATION BILLING REMIT <br /> REMITTANCE" $ AMOUNT DUE CHECKED <br /> G DATE DATE REMITTED AMOUNT <br /> FEE J D' �+- C�I SD.CX, <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 /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> Q- / Z_ <br />