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ENGINEER'S AND/OR <br />APPLICANT'S ANDIOR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />IrF.NSE AND/OR <br />3TRATION <br />Applications Will Be Processed When Submitted Properly Completed. Be SurL-ro Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOOD ESTABLISHMENTS. HOUSING <br />PUBLIC POOLS. WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make _- - - <br />Lic. No. -- -- - - <br />Regist. No - --- <br />I. .BER <br />(Application Date _20VP�-7Business/Name To Appear On Permit <br />o Type Permit/Service Flikayeste24 -------- <br />`.._� /L — Address-. <br />Applicant Name — ��, s <br />u � � �� Emergency Telephone No. <br />Business Tel�on�� o. ___. `� Y P I � � <br />�PrppeFly Location/Address <br />�Property Owner SLC .. .. Address <br />LOperator'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 .9 <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA 0 WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds — <br />r :ENNEL/Runways __ /Animal Population No. __ No. of Confining Cages <br />Sewage Disposal Method - <br />Solid Waste Disposal Method <br />Water Supply Source _ Animal Waste Disposal Method <br />6. ❑ CONSULTATION FEE (Jy C S <br />7. 0 PLAN CHECKING FEE — <br />8. REAL ESTATE <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 />RICH - MART <br />JIM THORPE. DISTRIBUTOR OF QUALITY PRODUCTS <br />368-6175 462.4581 <br />A 351 NO. BECKMAN ROAD, P.O. BOX 357 <br />r; LODI, CA 95241-0357 <br />TorwL <br />uwurrt of cNac. <br />PAY <br />TOTHE <br />ORDER OF <br />LODI OFFICE <br />IN W. WHnur A.. Lodi. CA 95110 <br />/✓/C.', <br /> <br />10189 <br /> <br />�j DOLLARS <br />L <br />flccened by Dale. Receipt No. Permit No. Issuance Date Mailed Delivered <br />__ _.._.___..._.._.. <br />----------- en An. OeOe STOOKTON. CA 951 <br />