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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) SEPTAC-E <br /> ENVIRONMENTAL HEALTH PERMIT V4-5 yZ-11i'll <br /> LIQUID WASTE 1�� <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> „Business Name (DBA) WONG ENGINEERS , INC. Address 4578 FEATHER RIVER DR. SUITE A <br /> < Owner C. CHANCE WONG Address STOCKTONf CA 95219 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 476-0011 Emergency Telephone No <br /> Contractor Licence No. <br /> Applicants Name (Print) C. CHANCE WONG Tice PRES. Date 4-15-92 <br /> Please 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 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. M 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 WEST OF 12881 E_ COMSTOCK Test Date/Time <br /> e. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT f� <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW 13 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 /> Home owner or Rceneed Seent•sU9neture certHtee thefoaowini:'l rert'ify that in the performance of Me work for which this permit is issued.I shall not employ any person C\ <br /> in such manner as to become subjem to wcckrna�i s conrpewatien taws of Caffiferni3 <br /> COmmetor's Nrl" or subconnacting signature cert)ftas the folk wing: "I certify that in the performance of the work for which this permit is issued.)shag <br /> MIWby persons subjectto workman's compensation laws of Califomla." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ` <br /> ordinances, state laws, and rL��Jj�n(�[j�� lations of Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X v�A t <br /> FOR DEPARTMENT USE ONLY <br /> Fee 19 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE C. N'PS Z 4 6� L�2ea 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `+- S L `f J7 <br /> Receiv�pdy Date Receipt No. Permit No. Issuance Date Mailed Delmemd <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bea 2009 STOCKTON,CA 95"1 <br />