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Applications Will Be Process*hen Submitted Properly Completed. Be Sure TThe Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR F000 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 /> IrFNSE AND/OR POULTRY RANCHES AND KENNELS - <br /> 3TRATION MISCELLANEOUS SERVICES Reglst. No. <br /> I. .BER Color <br /> I <br /> j Application Date _ Business/N me To App <br /> e n <br /> On Permit <br /> NType Permit/Service Requested,.--K}'�;•, r ! `-� 1�' ,,- � f, <br /> uAppllcar t Name -` �' "T_ / / - Address i <br /> c - Business Telephone No. � t �k-7 -c` Emergency Telephone No. <br /> '(Property Location/Address _-- L-J l �4 i, <br /> iProperty 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 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) PAYMENT <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NAIRECEiVe 4PPLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds �'1AY a 2 1989 <br /> :ENNEL/Runways /Animal Population No. No. of CDROM ges <br /> Sewage Disposal Method SAN JOAQUIN COUNTY <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Animal Waste Dispose etho <br /> e:. .; <br /> 6. ❑ CONSULTATION FEE <br /> T. ❑ 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, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X - - Title _ Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> — - - - AMOUNT <br /> FEE 117 tO <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.H"ELTON AVE_Yn-An.2001 RTnrKTnN CA 154n1 <br />