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r <br /> w Applications Will Be Ped When Submitted Properly Completed. BeS o Sign The Application. <br /> APPLICATION Sig <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <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 REAL ESTATE INSPECTIONS Lic. No. <br /> trENSE AND/OR POULTRY RANCHES AND KENNELS - <br /> 3TRATION MISCELLANEOUS SERVICES Reglsl. No. <br /> I, .dER <br /> c� Color <br /> f Application Date—O-3- Business/Name To A <br /> - ppear On Permit <br /> ,AType Permit/Service Requested:__ <br /> Applicant Name_ ' ,:� - Uh; <br /> u ---- s �� Address—33 6 -�y l�— <br /> ___ Business Telephone No._ Z z2 �— <br /> P �-_Z,L -- Emergency Telephone No. <br /> Property Location/Address <br /> <Property Owner MS MSv�o•� <br /> --------... -------- Address .1� <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 /> 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 44,2 <br /> 7. ❑ PLAN CHECKING FEE <br /> B. 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,,andrulesand regulations of the San Joaquin Local Health District. ,7 <br /> APPLICANT'S SIGNATURE X YCl�1 li��Yo /��' ccY �5jcr O <br /> —--- -------- Title �.,�.�.— __ Date 3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> —_--_— DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ----- ----------- — -- — — <br /> PRORATION <br /> ----------- -------------------------- <br /> PLUS - - --- — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br />