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_ ;6 771 <br /> �Gl. �pG D �3ati 0 ADO w• C�•k2�f� � Sy,�Ki _ �:1,i� <br /> AU-3 N 1 1993 <br /> ,,rv.;�ru �,L.HFA <br /> �5 <br /> /• iF Ati� � 7 <br /> /f�/oJv C.7P <br /> 2 • C' I/� /nus l 1.511 C? <br /> ,o be col/eckle <br /> /e <br /> X K <br /> pr �9rslPrerl ��i7/Q5/S� <br /> byWK�U / 7su• (2 /P <br /> �d2��V moi. PE72 X// ���•� )0` <br /> L. 6trRrlt,G <br /> d' � l�/''``�fi shfl.v w►,�ve bort�s -Fw'wtrnc.I�e� <br /> ej N1 r n e k- 2 <br /> gay.,rias a ¢ r-dj <br /> mcrM4WInIiireead5 ewrea� pas}� <br /> 17�ZCtst�r. +es we rnt5h� �eaQole FarQ�Qt. cR. "� s <br /> h� ,pat Ilett. � sr�.. Bari"_'a �•elvw-•i.�" cr' {�,Qarc to f�fev �- <br /> Qrll�w ci.�{�dV t2 tYu` S0yXA'rl4_ mike— 4r, Sc txy` <br /> 4. RECREATIONAL HEALTH U SWIMMING POOL U SPA U WADING POOL U NATURAL BATHING UPLACE <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 $35.00 <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 repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an ales and regulations of the San Joaquin Local Health District. 4 <br /> APPLICANT'S SIGNATURE X Title r Date �� �9�✓ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 Si Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.996 2009 STOCKTON.CA 25201 <br />