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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 Suspendabie) <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 /> Owner C. CHANCE WONG Address STOCKTON, CA 95 219 <br /> Firm Partners,Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. 476-0011 Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) <br /> C, CHANCE WONG Title PRES . Date 2-5-92 <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. JO 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 Location4005 S _ ROBERT Test Date/Time <br /> 4. ❑ SANITATION PERMIT N($_91-73 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0 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 /> Mon eowneror", w *9eW�s�+veeerl. o1ft1wltMleMrftfWsmWMeMMRfar wtl�e *WowiMis►lam/.fsWPsrenlpf"artyperson <br /> in such manner as to llimme sttect is tlrerkmalt`s of ea%o is <br /> 11 wowtor's hidn6 er sals cowuatoWq signs o onMse so fAnamAW i coTft li oMe peff6rAlitllts of the WW*Tw~this V~is issuN.I shall <br /> eegloy Persons subject t0ltrorkman s Cotialia" tiro liars W <br /> I hereby certify that I have prepared this application t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul tions oft an Aaquin 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE l0 1�tcs'V 'T-clZ •V D C [ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `1' - - <br /> Recei d_ Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLrZ:ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />