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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 0 CP <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdict+P� area of the L U�g Wavy l health Dis ict ri, CA <br /> H Business Name (DBA) Quality Control Inspection, Address 11 7 1V Lll1 <br /> z Owner Gary Fisher Address 23350 South Austin Rd. Ripon, <br /> Firm Partners, Addresses and Telephone Numbers <br /> ( 2 0 9 ) 599-3955 - Owner <br /> 0. Business Telephone No. ( 2 0 y ) 466—8378 Emergency Telephone No. —49 0 <br /> Contractor Licence No. N/A Testing, Inspection, Engineering Fir <br /> Applicants Name (Print) Jess s s Wry, O Q.C. I . Title P.E. Date 0 <br /> Please check Applicable Category (1-7)and Fill in the Required Information t � y5yv (n ,,�•�o <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. n PERCOLATION TEST LA-87-28 <br /> R.S. or R.C.E. Name Laver Roper R.S. or R.C.E. No. 5 . 555 <br /> Test Location See Map 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 <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 certify that hav ,prepared this application and that the work will be done in accordance with San Joaquin Co my <br /> ordinances, state laws, nd ules and r ulat ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> R MIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CH CKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS is �� <br /> PENALTY <br /> OTHER <br /> OTHER 7 <br /> Receive 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.Box 2009 STOCKTON, A 95201 <br />