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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />All, (For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br />H Business Name (DBA) WONG ENGINEERS INC Address 210 N. Hunter, Stockton 95202 <br />i Owner Address <br />a <br />Firm Partners, Addresses and Telephone Numbers <br />Business Telephone No. 464-4632 Emergency Telephone No... <br />< L Applicants Name (Print) C CHANCE WONG Title Pres. Date 4-24-84 <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. <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />CAL. License No. <br />Gal., Weights & Measures No. <br />CAL. License Renewal <br />No. of Chemical Toilets Stored <br />3. IC 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 30999 S. HOSTER ROAD Test Date/Time <br />4. ❑ SANITATION PERMIT PIPER PLACE S-83-8 <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />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 _ <br />Plant Location _ <br />Plant Capacity <br />No. Units Served <br />❑ PACKAGE PLANT <br />❑ OTHER <br />Where Certified <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 />Nome ownerorRcensea e90nt-saignaturacer6flesthe foffowing:1 certify That in theperformance of the work fur: h.` 1this permit is issued.) shall not employ any person <br />in such manner as to become subject to workman's compensation falvs of Calilmnia.' <br />Contactors hiring or sub -contracting signature oerrifies the following: `I cedify that in the performance M 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 prepared thi application and th a ork will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and�fj gt �i the San - 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 <br />EXPLANATION <br />BILLING REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE DATE <br />REMITTED <br />AMOUNT <br />FEE <br />t <br />LESS <br />PRORATION <br />PLUS <br />1A <br />PENALTY <br />XW1 <br />OTHER <br />OTHER <br />Z <br />Receiveo by ate Recelpl No, Permit No. iesuence Date Mailed Delivered <br />uenu,t.een U.— .bu C uefm. Tnu eve o n e... 1. srnCYrnu re OS9a1 <br />