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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 /> F Business Name (DBA) WONG ENGINEERS,INC. Address 4578 feather River #A, Stockton <br /> i Owner C. CHANCE WONG Address 95207 <br /> t <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. 476-0011 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) C. CHANCE WONG Title PRES. Date DEC. 119 1989 <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 9409 E. WATERLOO ROAD _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT MS—X89--73 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �r <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) f� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 . 'V <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 ownerorfkensed agerWs signature certifies the foflowing:"I certify that in the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's compensation laws of California:" <br /> Contractor's tiring or sub-contracting signature certifies the fonowin : "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of California:' <br /> I hereby certify that I have pr plication n that he work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r a g I ions of th an in Local Health District. _ <br /> APPLICANT'S SIGNATURE X <br /> s! �' <br /> :'�ONMENTA_L HEALTH <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 EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE Y{ d <br /> LESS <br /> PRORATION 00 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Datd 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 />