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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) <br /> SE AG� <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 /> rn Business Name (DBA) Quality Control Inspection, IncAddress 1295 N- Fmeral d Modesto 95351 <br /> < Owner Robert BOgetti & Sons Address P-n- Rom 797 VernaliS CA <br /> Firm Partners, Addresses and Telephone Numbers (209) 526-1515 <br /> A Business Telephone No. (209) 835-0208 Emergency Telephone No. (209) 527-4940 <br /> Contractor Licence No. NIA Engineering—Testing—LnSl1tCtion Firm <br /> L Applicants Name (Print) Q.C. T . B y Jess Wry. P $ Title P-E. Employee— Date 3/20.191 <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. 11 PERCOLATION TEST <br /> R.S. or R.C.E. Name Quality Control Inspection R.S. or R.C.E. No. / — <br /> Test Location See Map SIX Test LOcatie rMst Date/Time8,0oAtA <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 oertMer the t0li0win9:"I crrtithat in the performance of the work for which this permit is issued,I shall not employ any per <br /> son <br /> in such manner as to become subject to workma,t s compewation fa:vr a.ltur:•• <br /> corttraotor'a f'i'" or sub-contracting signature ca-rifk:, ::«� �toav'.r>p. 1 s = ': :'ti:in 1112 perfer:N,,vfcr^f'.he work for which this permit is issued,l shall <br /> employ persons subject to workmen's compensalio:i?Jw�.of C21itumia. <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, and rules and regulatio of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X S <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 t &Received By July 31 <br /> BASE EXPLANATION BILLING REMIT <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> �/ 'DAATEE DATE REMITTED AMOUNT <br /> � <br /> FEE �t/brf� w c� t Irl-1-9 <br /> LESS <br /> PRORATION 3 3ff q <br /> PLUS 9� /}C <br /> PENALTY '1 <br /> OTHER <br /> OTHER ( Q� <br /> 3-24 ! 1 V <br /> Reiv by Date eceipt No. Permit No. Issuance Date Mailed Delivered <br /> A LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />