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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) SEPTAL= <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) Quality Control Inspection Address 1295 N. Emerald Ave Modesto 95351 <br /> a Owner Carl & Nancy Serpa Address 29554 Grooms Rd Oakdale, CA 95361 <br /> u Firm Partners, Addresses and Telephone Numbers 0 838-2737 <br /> a Business Telephone No. (209) 754-3588 Emergency Telephone No. (209) 527-4940 <br /> � Contractor Licence No.N/A Engineering-Testing-Inspection Firm <br /> ` Applicants Name (Print) Q•C. 1. By Jess Wry Title P.E. Employee Date 11118191 <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 v <br /> 2. ❑ PUMPER YARD <br /> For July 1, . June 30, 19 tl\ <br /> No. of Vehicles Stored _ N <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST MS 91-83 <br /> R.S or R.C.E. NWe QUal i ty Control Inspection R.S. or R.C.E. No. <br /> Test Location -Jee rtaP Test Date/Time <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_ r1Cv <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 /> Homeowner or lican2ed agent's signature eo!"Ifl.s the foNoWhV:"I cert I1V thAr it the perform&nce of the work for which this permit is issued.I shall not employ vy p c rnn <br /> in such rlannei as to become sub;ect to woC ::':;'_co ttpensat c n f ra r:... <br /> Contractor's hiring nr sub-c;MracBng -.63natum cartifies the !ouowing: "I certify that in the performance of the work far which this permit is issued,I sha,, <br /> employ Pei SOn$au5ject to.vorkc3a's co:cpensstion laws 01 CalifOr:tia. <br /> I hereby certify tha TrIes <br /> pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, anan reg tions of the San Joaquin Local H alth District.APPLICANT'S SIGNATURE X - f��o� <br /> .lop <br /> Jess Wry, P.E. i <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> C� AMOU�yN/T' <br /> FEE �� 1 <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />