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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 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 /> a Owner C CHANCE WONG _ Address STOCKTON, CA 95219 <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 476-0011 Emergency Telephone No. _ <br /> Contractor Licence No. <br /> a Applicants Name (Print) C _ CHANCE WONG Title PRES. _ Date DEC, 9. 1991 <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. W 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 KASSON ROAD AT <br /> 4. ❑ SANITATION PERMIT RAILROAD MS_92-2 <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 /> Homeowner orlicensedagent's si naturecettffiesthefollowing:"Icertifythatintheperformanreoftheworkforwhichthispermitisissued,I3hatinotemployanyr <br /> in such manner as to hecomP Subject to workman's compemmion laws of California' <br /> Contractor's h4ing or suh-contractir+g signature certifies the following: A certify that In the performance of the work inr tv.``^: 1`' r-' <br /> employ persons subject to workman's compensation iaws of California.' <br /> i hereby certify that I have prepared this applicat10 that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul lations of�Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> - s G�� Q 9Y3S <br /> FEE leg /a�`l� �a-p-1� � <br /> LESS <br /> PRORATIONPLUS <br /> G <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec wed 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 />