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. ��` ••'l ! Applications WIII Be Pr .ssed When Submitted Properly Completed. Be Sure Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING <br /> APPLICANT'S AND/ORMake " <br /> CONTRACTOR ANDiOR PUBLIC POOLS.WATER SAMPLING — <br /> BROKER AND/OR REAL ESTATE INSPRANCHES <br /> AND <br /> KE Lig. st. - <br /> IrFNSEAND/OR POULTRY NEOUS RVI KERNELS Rapist. NO.-__ --- -.--- <br /> 1 MISCELLANEOUS SERVICES <br /> 1 iTRATION QOIOr —. <br /> I. .BER <br /> Application Date_�Q=�fL - Business/Name To Appear On Permit ---. <br /> Type Permit/Service Requested:_ --- -- G — <br /> QAp licant Name ��uJlhY-�L --LCHr Lcil - Address �..1�2 TIil P,rl"tF <br /> 7 A c- �-_Z� _ _ 1_9929L5 Business Telephone No. �I-I ROn , Emergency Telephone No.' ' <br /> n C LYf — <br /> aPropertyLocation/Address- k M ,1 <br /> Properly Owner L - l Address <br /> a ��5�_G� Address, T~ �e �� •�.d ze 4.60 n l'.a 9YS7X - <br /> - Operator's Name 1,y¢/ <br /> 1. FOOD ESTABLISHMENTS Tota Build g 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 11 CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER OUALITY ❑ 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 TNNEL/Runways --- /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method— <br /> Solid Waste Disposal Method <br /> _ Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. CONSULTATION FEE T Su L _CN <br /> 7. ❑ 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 /> Service Request For Date <br /> -- <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 <br /> Title 1 lrllci jC0iO Date U O <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITBy uly 31 <br /> BASE EXPLANATION BILLIN-�Gf�((//1 REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE- DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER LD I , <br /> OTHER <br /> L _ <br /> Rey eB by Date Receipt No. Permo No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bow 2009 STOCKTON.CA 95201 <br />