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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) SEPTAGE <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)Quality COIItr01 IIISDeCt10II, T_Ylc Address1295 N_ Fmt-rald Mndesto 95351 <br /> ownerGeorge Vin Weerdhuizen Address 26159 E Magnnl i a Fcealon 95320 <br /> j Firm Partners, Addresses and Telephone Numbers (209) 599-6450 <br /> Business Telephone No. (209) 527-4940 Emergency Telephone No. 527-4940 <br /> Contractor Licence No. NIA Engineering-Testi ng-Tn1IIPntion Firm <br /> L Applicants Name (Print) Q-C- I - By Jess Wry Title P.E. , Employee Date 3l 10/92 <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 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. ID PERCOLATION TEST <br /> R.S.or R.C.E. NameQuality Control Inspection R.S.or R.C.E. No. MS- —4 <br /> Test Location See map Test Date/Time Will Call__ <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 /> S. ❑ 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 /> figrtteswearorlicensedmsubjsignature <br /> mao.,icothefioflowlra "t certifytlY.itifheperformanceoftheworkforwhichthispermitisissued,Ishallnotemployanyperso <br /> !"such tti�nlfier as;o become subject to workmar?'s eompensation{ours of <br /> employC0111111111111persons <br /> hiring or km^b�� aignion la certifies ttte totiowfeg: A eellify(qat iG the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of t:alifornia." <br /> 1 hereby certify th 1 have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I and r les a r lotions of the San Joaquin Local Health District. <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 /> $ <br /> BASE EXPLANATION <br /> BILLING REMITTANCE REMIT DATE DATE REMITTED AMOUNT DUE CHECKED <br /> a� AMOUNT <br /> FEE �� 6 ��J 1 �' { Z-- �••Z 2 �O L 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2-9 z 7 <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 />