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- _ •.YAG :'. <br /> Appllcat!ona Will Be Pra;_eovd Fhn fluun4ad pr,sperlj Conplatkd.fill Sure 70 Sign The APD11 <br /> atMn. <br /> r <br /> t' T P1olt•1'rrsea€seralt0a,Prevocaboo,and Ssu*136r dable) SEPTAGE <br /> ENVIPIS NVI ENTAL 9 EALTH PERMIT r <br /> U-4XIM WASTE <br /> App;icatlon M hereby made to carry on business in the jurisdictional area of the San Josquln Local Health District <br /> 8._1slna�s Nomr (DBAp ._ ttald_SI-PL'i:C. SF;rviCQ_____ - Addrer;a <br /> x Owner - T. a. McDonald Address._-- <br /> " Firm Partners. Addre"as and Telephone NUMIWS <br /> Susmess Telephone No. 931-0497 Emergency Telephone No. <br /> Contactor Licence No <br /> Aonllcanls Name (Print) Date--- <br /> Pleas*chock Applicable CStegory(1-1)and FIN In the Required Inf^-rnagon <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) � <br /> !:or July I,.--June 30,19 Disposal Sies .._•_-..__. . ._._..___.__`—._. --___._ <br /> Duscripti,n(Make/Yr.,Color}__ _- --•----_.-----_._._ - —__ -------- <br /> Serial No.--_----------._---- CAL.License No. CAL.Lktwme Renewal No. _ - <br /> Capacity---_._.---- -- Gal.,weigtits A Measures No. - <br /> Equipment Parking Address - <br /> p. 0 PUMPER YARD �"• ... <br /> Fc,r July 1, ___ _ June 30. 19 <br /> trn. of vehtc-les Stored --------------__ -, _._._._.--_- —_ <br /> No of Cherr•icai Toilets Stored _ ---r ---- ----- --` <br /> -3. © PERCOLATION TEST <br /> R'S.or R.C.E.Name ._. _ ... R.S.or R.C.E.No. <br /> Test Location - _--- ----_.._.__... Test Date/Time <br /> d. 0 SANITATION PERMIT <br /> Job Addrassltocrstion I J�7 ----- <br /> Owner---. �•FA'— r�y��ya?----- -.-.. Add a�S_ .. ---- <br /> ❑ SEPTIC TANK ❑ CESSPOOL + -lam" 1_µ.AC TING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ ftt�JEt*1�..... <br /> ❑ TEMPORARY �ONEW REPAIR OTHER 5u1 <br /> 17 <br /> s <br /> rH EMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction.-____ ____ Disposal SiteNo.of Units ---_--_--_- ____Equipment Storage/Cleaning Location(s)_.-- ----------a. 13❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19__----. <br /> Upl9ratoe AlalTlo _-___-�---- _--- -------�= - '�IltlereCertitied ____--- --_--- <br /> -- 7- --- _---- <br /> Plant I_ocotinn __ --- -- -- -_--`-- <br /> Plant Capacity_._ --_- ----_•-------Not Unita Served ;, _ ------ ---- <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1.000 Sq,tit •; <br /> ❑ DRY CLEANING,Chemicals Llsed/Amount/Mo. <br /> I horoby certify thAt I have prepared this application and 'hat the work will be done in ac..ordance with San Joaquin County <br /> ordinances,state Iowa,end ruI ndAre�ulatbr tl�San Joaquin Loser allh District. - -- - -- -- -- <br /> APPLICANT'S SIGNATURE X - f - ---- <br /> FOR. EPARTMENT U 9 LY <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT PER BITE'K ❑ EACH ❑ hoary t a Received By January 31 Juwy I a Reserved Hy July 31 <br /> - ------ --- - REMIT <br /> BASE EXPLANATION <br /> BILL No —ITTANCE _ AMOUNT DUE 1 CHECKED <br /> I DATE ATE REMITTED AMOUNT <br /> FEE ,,.�y <br /> LESS t <br /> PRORATION .- - <br /> PLUS <br /> PENALTY ------ -- <br /> OTHER ! <br /> -.--—A <br /> OTHER c <br /> mil _-__ - ieauana-- tFii� I veer <br />