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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> W Business Name (DBA) World Enterprises Address P• ® , Box 8 598 , Stockton 95208 <br /> z Owner )')05�&XXMMXXUAddress X927--Clark Drive , Stockton, Ca. <br /> Firm Partners, Addresses and Telephone Numbers Rex Whorton Don Lawley - Go-Owners <br /> aBusiness Telephone No. 466—o717 Emergency Telephone No. <br /> Contractor Licence No. I�I <br /> Applicants Name (Print) ona aW ey Title 0 Wrier Date 2 4 <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 (a <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Dale/Time d <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 300, & 326 Madera Stockton Ca. <br /> Owner California Gedar Products Address 1340 W. Washington, Stockton <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR IXOTHER 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 Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant LocationI-- <br /> Plant <br /> f <br /> 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. <br /> I 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, a rules and regulations of th San Joaq 'n Local H Ith District. <br /> APPLICANT'S SIGNATURE X <br /> ,tom1 FOR DEPARTMENT USE ONLY <br /> 110 <br /> Fee Is Due: ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE Lfsr i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received byy ate Receipt No. Permit No. Issuance Date Mailed 4e, ere <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 9 01 <br />