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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. /a = <br /> APPLICATION A_4 a,lYK 3'3`0 <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTACE <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 /> H Business Name (DBA)Quality Control Inspection, InCAddress 1295 N. Emerald Modesto, CA 95351 <br /> i Owner Robert Boge t t i Address P.O. Box 791 Vernalis ' <br /> a <br /> J Firm Partners, Addresses and Tele hone Numbers (209) 526-1515 <br /> a Business Telephone No. (209p) 482-1418 Emergency Telephone No.(209) 527-4940 <br /> 4 Contractor Licence No. N/A Engineering-Testing-Inspection Firm <br /> �Applicants Name (Print) n C I By Jess Wry, P E Title P-R- F.mn1 oTee Date 3/12.19 1 <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. f Chemical Toilets Stored II <br /> 3. A PERCOLATION TEST —/lo Ips <br /> R.S. or R.C.E. Name Quality Control Inspection R.S. or R.C.E. No. MS ()0- 191 <br /> Test Location See Mal) Test Date/Time 3.115191 <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 owner or licensed agent's signature certifies the following:"l certify that inthepertnt,mariceof thp.work forwhich this permit is issued,I shall not employ any son <br /> in such manner as to become subject to workman's compensation laws of C. rformi- ' <br /> Contractors hiring or sub-ormacting signature certifies ttm, following: `I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation taws of California." <br /> I hereby certify t Mhavep d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, statlar gulati s 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION ZIA DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE � �a �j <br /> - <br /> LESS <br /> �'7 ( 3—)� I 42--Y-,6V 5D 15L <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER a F's Gti <br /> OTHER <br /> AA <br /> �6 ?� <br /> Receive y ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APP CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />