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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 car,on business in the jurisdictional area of the San J a uln Local Health District <br /> -Business Name (D BA) �a i�i0'�Ci h=QG IN1ryCH9. I'4C. Address `157 OEAT?I LrFt RIVER DR. SUITS A <br /> i Owner C. CLUNCB WONG Address STOCHTON, CA 95207 <br /> 4 <br /> u Firm Partners. Addresses and Telephone Numbers <br /> aBusiness Telephone No. 'L �u-0011 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) C. ClL1NCS WONG Title PRES.• Date JUNE 8• 1990 <br /> Please cheek 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. 13 PERCOLATION TEST <br /> R.S.or R.C.E. Name C. CUAYCE WONG R.S.or R.C.E.No. R.C.E. 14269 <br /> Test Location 11 710 d. LOUSE AVE. Test Date/Time <br /> 4. ❑ SANITATION PERMIT )LA-90-56 <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 C <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ✓j, FAV�I <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. VV <br /> 0sa Nyf 0 <br /> Mi FNT l <br /> !; q y� <br /> I hereby certify that I have prepared this ap lication an t work will be done in accordance with San J I joy <br /> ordinances, state laws, and rul I ns of the a Jo in Local 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r�Q r j^\£+ ,CO <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 1501 E.HAZELTON AVE.,P.O.0.2009 STOCKTON,CA 95201 <br />