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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> APPLICATION <br /> v (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is herebymade to carry on business in the juri§dictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA) WorlEnter rises —Address-Pe 0 & Box 8 598 , Stockton 9520.8 <br /> 4Ownerr ��X � Address 927-Clark Drive , Stockton Ca. <br /> 0 Firm Partners, Addresses and Telephone Numbers Rex Whorton Don 1awley - Co-Owners <br /> CL Business Telephone No. xix 466--0 17 _ Emergency Telephone No. 0,. <br /> Contractor Licence No. 6 59 64 <br /> Applicants Name (Print) on Lawley Title O Wrier Date 4 <br /> t <br /> Please check Applicable Category (1-7) and Fill in the Required Information Q <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 l <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 i <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 <br /> Job Address/Location 300' & 326 Madera, Stockton,—Ca <br /> owner—California CeProducts 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 Location <br /> Plant 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,i-01*rules and regulations of th San Joaq n Local H Ith District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT M7 PER SITE ❑ EACH 11 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 7� <br /> LESS <br /> PROBATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received bf ate Receipt No. Permit No. Issuance Date Mailed 4eiver. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCK ON,CA 9 01 <br />