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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGI <br /> LIQUID WASTE <br /> Application is hergbx rr�ad'eo carry or)business in the jurisdictional area of e S Joa uin Lo al He Ith District <br /> rn Business Name DBA Wor a �;n er •rises . 1. �ox- g�9 Stockton , 95208 <br /> I Address <br /> a Owner—. Address <br /> 0 Firm Partners, Addresses and T@le,p hone Numbers Rex 'Whortn' & Don 'Lawle - 27 Clark' Dr. Stk 20 <br /> CL <br /> Business Telephone No: 4 66-0 71.'7 <br /> -F' 2 " 9 v Emergency Telephone No. <br /> Contractor Licence Na 4 , <br /> Applicants Name (Print) - Barbara Lawle n. - J <br /> F Tltle Off z c e Manatee r Dace_ June 2 1981 <br /> Please check Applicable Category(1-7).and Fill in the Required Information ,. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r rhe} } fz x ` ►2 t <br /> For July 1; June 30;-19 _.,.- =f .Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. <br /> Capacity Gal.,-WeightsCAL. License Renewal No. <br /> ,�Weights &-Measures No. <br /> Equipment Parking Address <br /> 2. Q PUMPER YARD <br /> 'For Jul 1 - <br /> Y , June 30,49--�� ..�.w.......— -w�.��o�"�-.:�..,� .».. . .,....... ... <br /> No. of Vehicles Stored Y - <br /> .No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST- f t <br /> 'R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Test Location Test Date/Time (. <br /> 4. USANITATION PERMIT <br /> Job Address/Location 2028 S. Olive Street, . tocktori Ca . <br /> Owner State Savings & Doan 1 Address 7920 Lower Sacramento Rd o Stockto , <br /> ❑ SEPTIC TANK ❑ CESSPOOL. ❑-LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 1:1TEMP0RARY ❑ NEW 11 REPAIR OTHER Septic Tank Removal <br /> S. 1:1 CHEMICAL TOILETS For July 1, <br /> Type Construction + Disposal Site <br /> No. of Units Equipment:Stor'age/,Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 1$ 1k r <br /> } , <br /> Operator Name € _ . o Where Certified <br /> Plant Location I 11 <br /> Plant Capacity r No. Units Served C <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 Llsed/Amount/MO. ( ` <br /> 4 <br /> 7 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f <br /> ordinances, state laws, and s and regulations of the San Joa in 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 Jany .r 31 <br /> Y ❑ July 1 &Received By July31 <br /> BASE EXPLANATION BILLING REMITTANCE $ - REMIT ' <br /> e DATE - DATE REMITTED. _AMOUNTDUE CHECKED ° <br /> FEE AMOUNT <br /> LESS <br /> .. PRORATION <br /> PLUS ✓ " <br /> PENALTY' <br /> OTHER r� <br /> OTHER <br /> a <br /> Received by D to Receipt No. Permit No. ., <br /> d Delivered <br /> APPLICANT—RETLIRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - {1601 E.HAZELTON AVE.,P.O.Box 2009 t STOCKTON,CA 96201 4 <br /> i <br />