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n 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 /> m Business Name (DBA) WONG ENGINEERS t INC Address 210 N HUNTER ST. , STOCKTON <br /> i Owner C CHANCE WONG Address 95202 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q. <br /> Business Telephone No. 464-4632 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) C CHANCE WONG Title FRES• Date 8 NOV 83 <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. M 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 6033 CHEROKEE ROAD Test Date/Time <br /> 4. ❑ SANITATION PERMIT HAGAN ACRES S«-82. 8 <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 ortieansed agent's signature caninesthefollowing:"I certify that In the performance ofthe work fnrwhich this permitisissued,I shall not employ any pc - - <br /> in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: -I certify that in the performance W the work for which this permit is issuer,',I;;v <br /> employ persons subject toworkman's compensation laws of California.' <br /> I hereby certify that I have prepared this application and that rk will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and he San J Lit at Health District. <br /> APPLICANT'S SIGNATURE <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 g <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE O Ci . O o <br /> LESS <br /> PRORATION <br /> PLUS //Q <br /> PENALTY <br /> OTHER <br /> OTHER <br /> p —C� , SS <br /> Received by Date Receipt NNo. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1001 E.HAZELTON AVE.,P.O.Box 2009 STdCKTON,CA 95201 <br /> _ - w <br />