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t Applications Will Be Pr sed When Submitted Properly Completed. Be 1asaTo Sign The Application. <br /> APPLICATION <br /> a <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGIER`S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. — <br /> ,ir.FNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No.p <br /> 3TRATION MISCELLANEOUS SERVICES _�--- <br /> i. BER -- -- - Color <br /> 'Application Date _ — Business/N��OAPAdd <br /> it -..--- -- <br /> (aType Permit/Ser Requested: —a Applicant Nam s <br /> - — in Telephone N _ Emergency Telephone No. <br /> a Property Location/ ddress G ---- <br /> a Property 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 0 MEAT MARKET <br /> ❑ FOOD PROCESSING:PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> 13 ROADSIDE FOOD STAND ❑_LIQUOR STORE 11-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 CROPHARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> 11 HOTEL/MOTEL/No. of Units CERTIFICATE OF OCCUPANCY <br /> MOBILE HOME PARK/No. of Spaces <br /> -3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 11 PUBLIC WATER SYSTEM 0 SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> . RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SPA ❑ WADING POOL 13 NATURAL BATHING PLACE <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. El SLT FEE <br /> 7. PLA CHECKING FEE . > <br /> a. 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 /> APPLICANT'S SIGNATURE X �� _ Title Date 40 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> g AMOUNT_ <br /> EEE <br /> LESS 6 <br /> PRORATION <br /> PLUS <br /> PENALTY , <br /> OTHER <br /> OTHER <br /> Lyedby Date Receipt No. Permit No. Issuance Date M W Delivered <br /> NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 9601 E.HAZELTON'AVE..P.O.Box 2009-- STOCKTON,CA 95201 <br /> L <br />