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Applications Will Be Proc- -ed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> .EN41NEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .Ir`ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES R@gist. NO. <br /> I. .OER Color <br /> [Application Date _o?� Business/Name To Appear On Permit <br /> IMType Permit/Service Requested: <br /> Applicant Name Address <br /> D_ <br /> Business Telephon N 3 7 Emergency Telephone o. <br /> (Property Location/Address� �� <br /> Property Owner Address <br /> - Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 0. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> r :ENNEL/Runways /Animal Population No. No.of Confining Cagelp AYM ENT <br /> Sewage Disposal Method RECEIVED <br /> Solid Waste Disposal Method <br /> Water Su urce Animal Waste Disposal Method 11 IN 4 MR <br /> 6. CON TION FEE <br /> 7. V,4eCAN CHECKING FEE 0MRONMENM I &4n 1 <br /> 8. REAL ESTATE PRMITIM'010ES <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> I hereby certify that I have prepare this pliratiew.a(td that the work will be done in accordance with San Joaquin County <br /> ordinances, state law and r les a gala s of t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title c Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> o�- <br /> FEE 30 AJC Ck— AEG.ii <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 00 <br /> Recaivetl by Date '* /��pt No. Permit No. Imot ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIROpMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZERON AVE,P.O.Boa 20AY STOCKTON,CA RZD <br />