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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 Susper le) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebymade to carry op business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) WorlEnterprises_ Address P. 0 . aBox 8598 , Stk, Cd. 95208 <br /> z Owner Address <br /> Firm Partners, Addresses an p rs Rex Whorton & Don Lawley 6_6= 717 <br /> 0 1b3- 380 <br /> a. Business Telephone No. .. Emergency Telephone No. <br /> Contractor Licence No._ �2 59 <br /> 64 <br /> L Applicants Name (Print) Barbara' Lawley. Title Off ICL.Manager Date 'Way <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. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. �- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <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. ❑ SANITATION PERMIT Y <br /> Job Address/Location <br /> 2819 South Lincoln Street, Stockton, Ca. # <br /> Owner City of Stockt6nn-Comm.. Dev o Address Purchase Order No. 94169 <br /> t <br /> .❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT „I <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR XXOTHER Septic TaiA Removal <br /> 5. C1CHEMICAL TOILETS For July 1, -June 30, 19 it <br /> i <br /> Type Construction' Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) F <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where'Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 3 <br /> I hereby certify that I have prepared this application and that the work will be '©ne in ac ce with San Joaquin County <br /> ordinances, state laws, a rules and regulations of the San Joaquin Local H64 <br /> t <br /> APPLICANT'S SIGNATURE-X 1 <br /> FOR DEPARTMENT USE &II <br /> y� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT: ❑ PER SITE ❑ EACH ary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING EMT ANCE $ <br /> BASE EXPLANATION DATE ATE AMOUNT DUE CHECKED <br /> REMITTED <br /> - AMOUNT <br /> I 0 <br /> FEE - ! <br /> LESS <br /> PRORATION <br /> PLUS G <br /> PENALTY <br /> „OTHER <br /> . OTHER r _ <br /> Received by fDatel I Receipt No. Permit No Issuance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON A .O.Box 2009 STOCKTON,CA 95201 <br />