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( Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppllcauon. <br /> APPLICATION <br /> -4-' (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Worlds!Enterprises, Inc. AddressP• .© • 13ox 8598, Stockton 208 <br /> z Owner Address <br /> Firm Partners, Addresses and Tele hone Numbers .-� <br /> aBusiness Telephone No. 466-o 1 Emergency Telephone No. <br /> Contractor Licence No. A 265964 6 g <br /> 4 Donald LawleyTitle President_ Date <br /> L Applicants Name (Print) <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 11L Disposal Sites <br /> Description(Make/Yr., Color) <br /> I Serial No. I� CAL. License No. CAL. License Renewal No. <br /> Capacity I� Gal.,Weights & Measures No. <br /> Equipment Parking Address �M <br /> I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 .I 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 11 Test Date/Time <br /> 4. ❑ SANITATION PERMIT 142,7 S. Golden Gate , Ave . , Stockton, Cas <br /> Job Address/Location 20 <br /> Owner - A. Hayes '!I Address P• ©• Box 8 Stockton Ca. <br /> El PACKAGE PLAN] <br /> 11 SEPTIC TANK E) CESSPOOL 1:1 LEACHING FIELD ❑ SEEPAGE PIT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ® OTHER Septic Tank Removal <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction 11 Disposal Site <br /> ' No. of Units IK Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I` Where Certified <br /> Plant Location <br /> I Plant Capacity No. Units Served <br /> I 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 <br /> I <br /> I , <br /> I <br /> I hereby certify thatliI have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru!pond regulatio of t e S Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X �II <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY I ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIT By July 31 <br /> I� BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS II, <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 11 <br /> L r <br /> OTHER <br /> Received by Dat Receipt No. Permit No Issuance Date Mailed Deliver <br /> - APPLICANT—RETURN ALL 41OPIES TO: ENVIRONMENTAL HEALTH�PERMITISERVICES 1601.E.HAZELTON AVE.,P.O.Box 2000 STOC ON,CA 95201 <br />