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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 /> a ENVIRONMENTAL HEALTH PERMIT <br /> - LIQUID WASTE u �- <br /> Application is hereby made to carry on business in the jurisdictional-area of the San Joaquin Local Health District. ,. r_ A <br /> N Business Name (DBA) WOr�CI Enterprises Address P. © 0 .,BOx' 8 8Y Stk ,-9 5208:' <br /> i <br /> aOwner _ x .. . .. Address. <br /> J Firm Partners, Addresses and Telephsne Numbers Rex Whorton '& Don' Lawley 466-'0717 <br /> aBusiness Telephone No. 4,M0 1 Emergency Telephone No. r <br /> Contractor Licence No. 2.6 59 64 <br /> Applicants Name (Print] Barbar .-Z . Title, ©fflr_e� gr pate <br /> Please check Applicable Category(1-7)-and Fill in the Required information ;..- F nL r. �,F„ t1�j , ..,�. , ;�,.�. I ob <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. w �` <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 r" <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 1 <br /> 4. IX SANITATION PERMIT <br /> Job Address/Location 9039 Davig Road Stockton C'a. <br /> owner Lo al Order of Moose address 9Davis Rd. Stockton Ca. 20 <br /> ❑ SEPTIC TANK 1:1 CESSPOOL 13 LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> 1:1 PERMANENT 4 ❑ TEMPORARY 11 NEW ❑ REPAIR OTHER Se ita Tank Removal <br /> 41. <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 d <br /> t <br /> Type ConstructionDisposal Site <br /> p <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name L:- Where Certified, <br /> K, <br /> Plant Location <br /> Plant Capacity No. Units Served !'f <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 /> 4 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with-San Joaquin County <br /> ' ordinances, state laws, an rules and regulations of he Sari Joaquin Local Health District. �. I <br /> APPLICANT'S SIGNATURE X <br /> r <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 /> i FEE I Q� <br /> LESS 1 <br /> PRORATION <br /> PLUS 6 <br /> PENALTY `t <br /> f OTHER <br /> OTHER <br /> Received by to ecei No. Permit No. Issuance to Mailed Delivered <br /> APP0CANT"RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />