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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> t 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 /> reusines a (DB )Quality Control Inspection. InCAddres 1295 N. Emerald Modesto 95351 <br /> ape associates Inc. P.O. �LS6Lodi� <br /> a Owner p Address <br /> Firm Partners, Addresses and Te one ,�n b�jr'�j 2 334-9664 <br /> 0. Business Telephone No. (2��� 4 3—` ` Emgrgenc Telephone No. <br /> Contractor Licence No. N/A Engineering-Testing-Ins ectlon Firm <br /> �Applicants Name (Print) Q•C. I. By Jess Wry, P.E. Title P•E. Employee Date 7 /91 <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. IN PERCOLATION TEST <br /> R.S. or R.C.E. Name Quality Control Inspection R.S.or R. .E. No. MS -A,/� <br /> - <br /> Test Location See Map Test Date/Time } s <br /> 4. ❑ SANITATION PERMIT Q —�d Q <br /> Job Address/Location d t�—�C — <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 TREATK*NT 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof the workfor which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's compensation laws of Cailfcrnia" <br /> Contractor's hiring or sub-contracting signature cartifies the fwlowing: 1 certify that in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to workman's compensation law,ul California." <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, a and regula ion j oof the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - �5 ' ` <br /> Jess Wry, P.E 12rc <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> 1 <br /> FEE 0Qo-" <br /> LESS Z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OO <br /> i c) <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.Boz 2009 STOCKTON,CA 95201 <br />