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Applications Will Be Pro!'~'ed When Submitted Properly Completed.Be sur--0 Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGI ERS A D OR <br />APPLICANTS AND'OR <br />CONTRACTORAND OR <br />BROKERAND,OR <br />rF:NSE AND OR <br />,TRATION <br />ilER <br />FOOO ESTABLISHMENTS.HOUSING <br />PUBLIC POOLS.WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES ANO KENNElS <br />MISCElLANEOUS SERVIC~S <br />IF VEHICLE INVOLVED,GIVE <br />Make <br />Lrc No <br />Reglst No <br />Color <br />Application Date 9!t,J /8%Business/Name To Appear On Permit /v6-Sfoofc"h /'-t..---"'"~_A,tA:>,A(. <br /><II Type Permit Service Requested.mo ,:/rJr,c:;l-v'ei{?~"-r-,t-5 Applicant Name t-va.."fe...-W ...-K...Address 17/0 ~c..I'" <br />~Business Telephone NO~.938-ss:2 <br />~property Location/Address 3).~0 ~J#-M.tlc...14M~Shck."iJ-....;-c/?- <br />~Property Owner rr,vaJl-ty ~~Address i)r~•..••.•c-/2-"./Y1c,,:/c-s/'o cCJ 'l5 S~~ <br />Operators Name Address <br />1.FOOD ESTABLISHMENTS Total BUilding Sq.Footage Restaurant,Maximum Seating CapacityoRESTAURANT0FOODMARKETRETAIL0FOODMARKETWHOLESALE0MEATMARKEToFOODPROCESSINGPLANT0COMMISSARY0ICEPLANT0BAKERYoROADSIDEFOODSTAND0LIQUORSTORE0BAR0ITINERANT RESTAURANToCONFECTIONARYSTORE0FOODSALVAGER0FOODDEMONSTRATION0FOODVENDORoVENDINGMACHINES/No of 0 MOBILE FOOD PREP UNIT 0 VENDING VEHICLEoFOODCROPHARVESTING/No.of Field Employees <br />ALL APPLICANTS Total Employees Including Operators _ <br />2.HOUSINGoHOTEL/MOTEUNo of UnitsoMOBILEHOMEPARK/No.of Spaces <br />3.WATER QUALITY 0 WATER SAMPLE (Bacterial)o PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY <br />NO OF PUBLIC SERVED (Connections)0 <br />4.RECREATIONAL HEALTH 0 SWIMMING POOL 0 SPA 0 WADING POOL 0 NATURAL BATHING PLACE <br />5.VECTOR CONTROL 0 POULTRY FARM/Maximum No.of Birdsr'ENNEURunways /Animal Population No. <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />Water Supply Source <br />6.0 CONSUL TAnON FEE <br />7.)(PLAN CHECKING FEE --------------------------------------- <br />8.REAL ESTATE <br />REQUEST Water Well Inspection 0 Sample 0 <br />Sewage System Inspection 0 <br />Escrow No <br />Seller <br />Telephone No <br />Service Request For Date <br />~~"6 F:..ceo//)..-.c,4.9S-s...2..Q <br />Emergency Telephone No.{).QCl)Er3'&'-sSC:? <br />o CERTIFICATE OF OCCUPANCY <br />CHEMICALoWATER HAULER <br />No.of Confining Cages _ <br />Animal Waste Disposal Method _ <br />Title Company <br />Address Tele.No._ <br />Seller Address <br />Seller Agent Name <br />APPLICANTS SIGNATURE X <br />the work will be done in accordance with San Joaquin County <br />aquin Local Health District. <br />Title ~~~,sie.-J6-ecIo)t/~t-S86~ate --'-'-.:..=-'--''''''''''_ <br />BI <br />D <br />REMITLliNGREMITTANCESAMOUNTDUECHECKEDATEDATEREMITTEDAMOUNT <br />- <br />-- <br />o July'&Received By July 31FeeIsDue:0 ANNUALLY o PER UNIT <br />BASE EXPLANATION <br />FEE <br />t <br />I <br />OTHER <br />LESSPRORATION <br />PLUSPENALTV L.OTHER <br />Issuance Date Mailed <br />1601E.HAZELTON AVE •.P.O.80.2009 <br />Delivered <br />STOCKTON.CA 952011-----' <br />Received by Date Receipt No Perml'No <br />ENVIRONMENTAL HEALTH PERMIT/SERVICESAPPLICANT-RETURN ALL COPIES TO: