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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 />, BusinessName(DBA)QUALITY CONTROL INSPECT. , INC. Address i295 N' Emera 6 Ave, -Modes o Ca <br />z Owner�-ral:tl.ine Hast Homes Address 6352 West: Canal— Tracy, Ca. <br />j Firm Partners, Addresses and Telephone Numbers (209) 835-465 1 <br />a. Business Telephone No. (2 09) 527-4940 Emergency Telephone No. f'l_ 09) 527-4940 <br />�Contractor Licence No.N/A— Engineering—Testing-Inspection First <br />Applicants Name (Print) g l% I by Jess Wry Title!'-mploynne Date! 127/88 <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 �l <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST <br />R.S. or R.C.E. Name 016ali ty Control Inspection R.S. or R.C.E. No. <br />Test Location �e�� i+izr (SU -8b— 12� Test Date/Timelii I I Ca11 .IHLT.88 to Feb 8b <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 />I hereby certthat I hale preparedthis ap lic Ion and that the work will be done in accordance with San Joaquin County <br />ordinances, sta ws, anQ rules and egulati ns ,f the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE XT <br />I� l F <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 <br />BASE EXPLANATION <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />'70o - <br />�v V <br />FEE <br />"ev <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />1 -27 -J -P <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />___..__. ... —�.�� �.. �............. �..�.. ..�., t.....-.....�,n�n.•,..�.. ..n. c uw-.c, Tnu wvc o n G.... Donn C n'.Tnu re <br />