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Applications Will Be PIDCessed When Submitted Property Completed. Be Sure` Io Sign The Application. <br />ENGINEER'S AND/OR <br />APPLICANTS AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />LICENSE AND/OR <br />REGISTRATION <br />NUMBER <br />F Application <br />Ty Date 6 _ G <br />w Type Permit/Service R , ues�tQd: <br />YApplicant Name t <br />Property Location/Atldress 2 <br />'Property Owner _coc <br />L Operator's Name Itik� <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />FOOD ESTABLISHMENTS, HOUSING Lic. No. <br />PUBLIC POOLS WATER SAMPLING Regist. I <br />REAL ESTATE INSPECTIONS Color_ <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />To Appear On Permit �C 04%1.02-[1,A <br />Address <br />Address <br />Emergency Telephone No. <br />I -MU Ca1AMLINMA1ENTS <br />❑ RESTAURANT ❑ <br />Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />FOOD MARKET RETAIL <br />❑ FOOD PROCESSING PLANT ❑ COMMISSARY <br />❑ FOOD MARKET WHOLESALE <br />❑ ICE PLANT <br />❑ MEAT MARKET <br />❑ BAKERY <br />❑ ROADSIDE FOOD STAND <br />❑ CONFECTIONARY STORE <br />❑ LIQUOR STORE <br />❑ FOOD <br />❑ BAR <br />❑ ITINERANT RESTAURANT <br />❑ VENDING MACHINES/No. <br />SALVAGER <br />❑ FOOD DEMONSTRATION <br />❑ FOOD VENDOR <br />of <br />❑ MOBILE FOOD PREP UNIT <br />❑ V <br />13FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />Z. HOUSING <br />C3HOTEUMOTEL/No. of Units <br />13MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ElWATER SAMPLE (Bacterial) 130 PUBLIC WATER SYSTEM 11SURFACE WATER SUPPLY <br />NO. OF PUBLIC SERVED (Connections) <br />a. RECREATIONAL HEALTH 13SWIMMING POOL 11SPA 13WADING POOL 13NATHRAl RATHINr: PI Arc <br />8. VECTOR CONTROL 13POULTRY FARM/Maximum No. of Birds <br />13KENNEURunwaya /Animal Population No. <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />ENDING VEHICLE <br />11 CERTIFICATE OF OCCUPANCY <br />CHEMICAL <br />11 WATER HAULER <br />No. of Confining Cages <br />Water Supply Source Animal Waste Disposal Method <br />S. CR CONSULTATION FEE ❑ BUSINESS LICENSE <br />T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br />B. REAL ESTATE <br />REQUEST: <br />Water Well Inspection 13 <br />Sewage System Inspection <br />Escrow No. <br />Seller <br />Sample ❑ Title Company <br />13Address <br />Seller Address <br />Telephone No. Seller Agent Name <br />Service Request For Date <br />Tele. No. <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 regul tions oof,01V San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X��l.--r� zw2nw7 �_ Title Y !� Date <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janus I S Receiv ed B <br />ry y January 31 ❑ July 1 6 Received By July 31 <br />BASE EXPLANATION BILLING REMITTANCE $ REMIT <br />DATE DATE REMITTED AMOUNTDUE CHECKED <br />AMOUNT <br />E � � // t� <br />w <br />lA/1I `b' d' e " / ?8 <br />RxeN by Date Raceipt N. ---Permll No <br />-APPLICANT- IHAZELe Date Mailed OOCKTd <br />aETWI{J1LyCOeIEa.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />1a01 E. HA2ELTON AVE., P.O. Ma 100E aTOCKTOM, CA 06101 - <br />lA/1I `b' d' e " / ?8 <br />RxeN by Date Raceipt N. ---Permll No <br />-APPLICANT- IHAZELe Date Mailed OOCKTd <br />aETWI{J1LyCOeIEa.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />1a01 E. HA2ELTON AVE., P.O. Ma 100E aTOCKTOM, CA 06101 - <br />