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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) SEP7AG.E <br /> N 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 /> rn Business Name'{DBA) <br /> Wo <br /> Enterprises Address P•. '0. Box 8 1 8 Stk .05208 <br /> z Owner- _. Address <br /> 4 Firm Partners, Addresses and Telephone Numbers ' -Rex Whorton - Don•�Lawley = 3922 Clark Dr. _ 466`-0717 <br /> CL Business Telephone No. _ 46b -0 l- Emergency Telephone ND. <br /> Contractor Licence No. 265964 . <br /> - <br /> Applicants Name (Print) Barbara Lawl-e Title^Off ice Manager Date 7-.14-81 - a <br /> Please check Applicable Category (1-7)and Fill in the Required lnformatlon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � <br /> For July 1, -June 30, 19 -"" - Disposal Sites <br /> cad <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 t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> i <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. ❑ SANITATION PERMIT E . <br /> Job Address/Location 260 On S�. Stockton, On. # <br /> Owner Address 2 0 ` 1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL = ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER Septic Tank Removal <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <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 6 <br /> Operator Name 1. Where Certified - -- C <br /> Plant Location <br /> Plant Capacity t. No. Units Served <br /> 7. ❑ LAUNDRY - For July 1, -June-30, 19 rt i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,, ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo" <br /> 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, an54ules and regulations of the San Joaquin Local Health District. t <br /> APPLICANT'S'SIGNAl URE X <br /> r 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 /> { <br /> O <br /> FEE 410 - <br /> LESS <br /> PRORAT4ON <br /> PLUS $ <br /> PENALTY <br /> OTHER r <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issuance a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTD .0.86.2009'- STOCKTON,CA 95201 _ <br />