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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) <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 a INC. Address 4578 FEATHER RIVER DR, , SUITE A <br /> <Owner C. CHANCE WAG Address STOCKTON, CA 95219 <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> a. Business Telephone No. 476-0011 Emergency Telephone No. <br /> � <br /> Contractor Licence No. <br /> �Applicants Name (Print) C. CHANCE WONG Title PRES. Date 12-18-91 <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. AN 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 Test Date/Time <br /> 4. ❑ SANITATION PERMIT MS-92-45 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 /> Harnn ovmerorlicenxA a.�e�t'�•Irn�+.m^sr°'0a ;t,�i�t!cmrinq l-r W fy lh-t in th^cc-'(1-mance of the work for which this permit is issued.I shall not employ any person <br /> in such manner as to t,.. <br /> Contractor's Wwhv or �;, Ir � w.ai;: t Gel 615y V:: ',in 1 e pens;Hance of the work for which this permit is issued,I shall <br /> em;Joypersons;,;b;ecitoworkman:,_)-; <br /> I hereby certify that I have prepared this application pnd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r a lations of an oaquin 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE ( <br /> LESS „pp 21`.Cr <br /> !2-( 9 7 It J Z-1 1 -9 f 2J Z.oa dZ <br /> PRORATION <br /> PLUS <br /> PENALTY Z S <br /> OTHER V " <br /> OTHER <br /> Heceivp,y Dae Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 F HA7F1 TON AVF c 0 w,..onno <br />