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ENVIRONMENTAL HEALTH PERMIT/SERVIC , <br /> ENGINEER'S AND/OR n VEHICLE INVOLVED,GIVE <br /> F000 ESTABLISHMENTS,HOUSING �i �� <br /> APPLICANT'S AND/ORY <br /> CONTRACTOR ANO/OR PUBLIC POOLS.WATER SAMPLING Make <br /> W <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .DENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES Color <br /> I. BER <br /> I <br /> Application Date <br /> lv 2� ujj"siness/Na a To Appe On ermit Pte` a <br /> FType Permit/Service Requested: � v <br /> iApplicantName Add(ess 7L'� <br /> Business Telephone N .�S/ 3'Z7 Emergency Telephone No. <br /> iProperty Location/ ddress <br /> J Property Owner 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 HOMIt 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 /> W er S�vpply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE I:?ddi4:iajna kat e yd <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well inspection SampleO 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 6 Received By January 31 ❑ July 1 d Received <br /> R MlTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> has S <br /> FEE <br /> JI`!l <br /> LESS <br /> PRORATION - -" <br /> PLUS <br /> PENALTY J/ i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE..V.O.60><2009 STOCKTOH,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />