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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ° ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebyY made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Worla Enterprises Address_P`e 0 . ' <br /> Box 8598, Stockton 25 08 <br /> - —c - - - <br /> z Owner Address <br /> J Firm Partners, Addresses and Tele hone Numbers Rex ,Whorton & Don` Hawley — 466071773927 ark Dr.Stk <br /> aBusiness Telephone No. T u 6p6`•071. Emergency Telephone No: 465-0152 <br /> 2 59 . <br /> Contractor Licence No. <br /> LApplicants Name (Print) Barbara. Lawley-. Title Office Manager Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information r <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. y <br /> .Capacity Gal., Weights & Measures No. <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 /> 4. U SANITATION PERMIT <br /> Job Address/Location 248 West Delhi Avenue Stockton Ca. <br /> Owner City of Stockton Gorit Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD D SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR BOTHER Septic Tank Removal <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site + <br /> No. of Units Equipment Storage/Cleaning Locations) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -'June 30, 19 ! <br /> Operator Name Where Certified <br /> Plant Location 3 4 <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. Y <br /> hereby certify that I-have prepared this application and that the work will be done in a or nce with San Joaquin County <br /> ordinances, state laws, and r sand regulations of t San Joaquin Local Health District. <br /> - � s <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE Y <br /> Fee Is Due' 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ 1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT T <br /> BILLING Imo.AI'vCE $ <br /> BASE EXPLANATION DATE E REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Li <br /> Received by Date Receipt No. - 'Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '"`1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,Cay <br />