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Applications Will Bet ssed When Submitted Properly Completed. Be To Sign The Application. <br /> ' <br /> APPLICATION _ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES r ' <br /> ENGINEER'S AND/OR <br /> APPLICANTS AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS,HOUSING "{ FV HIC,LNVOLVED, GIVE <br /> <" <br /> 1*KER AND/OR PUBLIC POOLS,WATER SAMPLING AMake <br /> 3NSE AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> POULTRY RANCHES AND KENNELS <br /> ARATION <br /> EMISCELLANEOUS SERVICES Regist. No. <br /> G y Color <br /> wApplication Date Busin ss/ me T A <br /> —,E` ppear On Permit <br /> FType Permit/Service a uested:—4` � -/ - <br /> Applicant Name s� Address i S� <br /> CIL — Business Telephone No. a6l 3 EmergencyTelephon o. <br /> a Property Location/Address OS s <br /> Property Owner /i1 _ Address _ F �—i4) CC S' <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 /> RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways _ /Animal Population No. _ No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method— <br /> Wat_T,,cgfPPly Source nimal Waste isposal Method <br /> 6. LT CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample El 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 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE _ DATE REMITTED AMOUNT DUE CHECKED <br /> FEE C I `/1 q12 <br /> 8AMOUNT7 LESSPRORATION <br /> PLUS <br /> PENALTY <br /> c"`T <br /> ' � OUNT �' <br /> OTHER <br /> -- 01 Lig'G Dr1T"E. <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br />