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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) t SE.PTAGE <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 #A; STOCKTON <br /> iOwner C . CHANCE WONG Address 95207 <br /> a 476-0011 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 476-0011 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) C . CHANCE WONG Title PRES. 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 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 C. CHANCE WONG R.S. or R.C.E. No. R.C.E. 14269 <br /> Test Location N.E. COR.FOPP IANO & HWY 99nm <br /> /Ti <br /> 4. ❑ SANITATION PERMIT . 89-21 RETE <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 or licensed-Sent'sscgnature certifies the foi!owing:"I cert ify that in the performance of thewarkfaf which this permit is issued,I shall not employ any per on <br /> in such manner as to become subjict to workman's compensation laws of Califol ilia.' <br /> Contractor's hiring or sub-contracting the cAlowng: 1 certify �1' <br /> ,th performaoce of the ork for wh c us er it is is^�ed I shall <br /> employ pe q@�j1+ ►f i)ffl�Aliieuenpel icecialknis, a and trtat th rk III�e done In accorfance wlt�1 SNn goa�quln G�ouhty <br /> ordinances, state laws, and rules and r a n of San Joaq Lo 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIOy AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE Vv O <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 />