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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) SEPTA( <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 />U) Business Name (DBA) QUAL ITY CONTROL I NSPECT., TNC _ Address 1295 N- Emerald Ave -Modesto, CES <br /><OwnerGrantline East Homes Address b_1? Wp-,f- Canal- Trac;, Ca <br />J Firm Partners, Addresses and Telephone Numbers (209) 835-4651 <br />a Business Telephone No. (209) 527-4940 Emergency Telephone No.(909T597-4940 <br />-i Contractor Licence No. N <br />/A— Fngin__ PPring_Teycfiinv—TncnPrtinn Firm <br />Applicants Name (Print) O C - T _ by TPRR Wry Title EM Iayee Date 1/27/88 <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. n <br />Capacity Gal., Weights & Measures No. 1 <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. ❑ PERCOLATION TEST <br />R.S. or R.C.E. Name 0ua 1�(,nntrO1 Inspec t ion R.S. or R.C.E. No. <br />Test Location See (�11— R F, — 12) 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 1 <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 <br />Plant Location <br />Plant Capacity <br />No. Units Served <br />Where Certified <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 orlicensedagent's signstumcertifies the following: "Ie rtifythatintheperformanceoftheworkforwhichthispermitisissued,Ishallnotemployanyperson <br />in such manner as to become subiea t ror!;r,r< <br />Contractor's hiring or sutr^c:. tf:e foi:owing: "I certify that in the performance of the work for which this permit is Issued, I shall <br />employ persons subject to W? -T.77 <br />I hereby certify N <br />ordinances, state I <br />APPLICANT'S SIGNATURE X <br />ared thp applicftioi and that the work will be done in accordance wl San Joaquin County <br />and re ulations f e San Joaquin Local Health District. 'IL <br />esf wry, <br />FOR DEPARTMENT USE ONLY v ' j/' j,I V, <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 & Received By Januar 31 ❑ July 1 & Received By July 31 <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E. HAZELTON AVE., P.O. Boz 2009 STOCKTON, CA 95201 — <br />REMIT <br />BASE <br />BILLING <br />EXPLANATION <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />//�� <br />-loo ' vo <br />(� <br />1 / o/ S <br />-700- 00 <br />LESS <br />PRORATION <br />- <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E. HAZELTON AVE., P.O. Boz 2009 STOCKTON, CA 95201 — <br />