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Applications Will Be Processed When Submitted Properly Completed. Be Sure I Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/ORMake -- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Lic. No. <br /> BROKER AND/OR F000 ESTABLISHMENTS.HOUSING <br /> LICENSE AND/OR PUBLIC POOLS,WATER SAMPLING Regist. NO. -- <br /> REGISTRATION REAL ESTATE INSPECTIONS Color <br /> NUMBER POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES _ <br /> FApplication Date Business/Name To Appear On Permit — -- <br /> aType Permit/Service Re%,e eQ <br /> Applicant Name 4 "0- ��t'�bT� Address - <br /> Busigqass Tlephone No. 73-2228 Emergency Telephone No. — <br /> Property Location/Address -C�IerOKee Lane, L0 _ <br /> Property Owner Union Oil Co. Address <br /> L 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 /> Z. 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 /> a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> ❑ KENNEL/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 /> S. It CONSULTATION FEE hr ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> 9. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company <br /> Sewage System Inspection ❑ Address_ Tale. 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 rule and regulations <br /> �offthe <br /> San jJoaquin Local Health District. A� <br /> APPLICANTS SIGNATUR `� ' = ¢ae' " Title-�.rrs�y Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee is DW: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 S Receivetl By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE' S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE $70.00 2 Hours 6/25/85 D e by 7/25/ 5 170. 0 <br /> LESS <br /> PRORATION fl•0 - <br /> PLUS / <br /> PENALTY <br /> OTHER �/Y <br /> 'a <br /> OTHER <br /> e <br /> g o <br /> i by <br /> ReceDate Receipt No. Permit No. Issuance Date Mailed ONIvarM r <br /> 11—APPLICANT—RETLMkA C RWA'rO: ERNHIONMENTAL HEALTH PERMITBERVICES INVE.HAZELTON AVE.,P.O.aex>AM STOONTOW CA s l <br /> w <br />