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Applications WIII Be Fir r ed When Submitted Properly Completed. Be S1 o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING Make <br /> BROKER AND/OR HEAL ESTATE INSPECTIONS LIC. NO. <br /> IrPNSE AND/OR POULTRY RANCHES AND KENNELS _ --- <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. AER __ <br /> Color <br /> [Application Date +n-t� -f Businss/Name To Appear On Permit •✓`-�r�,x�-•_-______�4 <br /> :Type Permit/Service Requested: - <br /> i Applicant Name Ad ass /"(y /Al• �Jh A.i i i <br /> u <br /> u Business TelepEmergency Telephone No. <br /> iProperty Location/Address/I,_^_. A. <br /> iProperty Owner W Address <br /> [Operator's Name - _. _J_�� 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 /> 4. 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 Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> Water Supply Source __-_ Animal Waste Disposal Method <br /> 6, CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> 6. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ 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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 6 Received By July 31 <br /> $BASE EXPLANATION <br /> BILLING REMITTANCE REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED @ AMOUNT_ <br /> FEE `!� �v/� 2/3/89 �•Sb .P .J b <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PEN,ALTI-S(_A/II,) Cir n. <br /> OTHER J-R. V 0 �'i..!li�'.'.. _, _ , � <br /> OTHER <br /> 17- <br /> Received y Dale Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALI.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 200 STOCKTON,CA 95:01 <br />