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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign T r,Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPT.ACt= <br /> 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 /> Business Name DBA)Qnality Control Inspection Address 1295 N. Emerald Modesto 95351 <br /> a Owner Ms. Barbara Larsen Address P•O• Box 174 Manteca 95336 _ <br /> Firm Partners, Addresses and Telephone Numbers Nolte & Assoc. (209) 239-90$0 <br /> CL <br /> Business Telephone No. (209) 527-4940 Emergency Telephone No, <br /> Contractor Licence No. N A Engineering-Testin -Ins ection Firm <br /> L Applicants Name (Print)Q,C- I . By Jess W.ry, P.E. TitfeP•E- Em to ee Date 3/1/92 <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 <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. ISI PERCOLATION TEST <br /> R.S. orR.C.E. NameQuality Control Inspection R.S. or R.C.E. No. MS-92-13 <br /> Test Location See Map Test Date/Time Will C-2ill <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> Home owneror licensed agent's signature cartifiesthe following:"I crrtify thM to fhe performance of the work for which this permit is issued,I shalt not employ any per"n <br /> In such manner as to becorpe subject to workma s compensation laws of C.atifatni6 <br /> Contractor's hiring or sub-contracting signature certifies the fotbwrfnq; 1 certify that irl the performance of the work for which this permit is issued I shall <br /> employ persons subject to workman's compensailon laws of California." <br /> I hereby certify t t 1 have epared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I and rul sand ego ions of the San Joaquin Local Health District. <br /> 7� <br /> APPLICANT'S SIGNATURE X <br /> Jess Wry, P.E. <br /> 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 /> FEE �Or <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 9�22 d YC g - - _- <br /> ce v d by a[e ­­PL PL No. t Permit Ncf Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />