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ENGINEER'S AND/OR <br />APPLICANT'S AND/OR <br />CONTRACTOR AND/OR <br />BROKER AND/OR <br />Ir-ENSE AND/OR <br />3TRATION <br />1. .8ER -- <br />Applications Will Be P ssed When Submitted Properly Completed. Be S To Sign The Application. <br />APPLICATION <br />NVIRONMENTAL HEALTH PERMIT/SERVICES - <br />IF VEHICLE INVOLVED, GIVE _ <br />FOOD ESTABLISHMENTS. HOUSING Make <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS Lic. No. <br />POULTRY RANCHES AND KENNELS Re 1st. No. <br />MISCELLANEOUS SERVICES g -- <br />Color <br />(Application Date /7 Business/I�ame•Ta AppAar bn P�r�nit_. ti <br />--�� <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 & Received By January 31 ❑July 1 &Received By July 3T <br />I <br />HType Permit/Service Reque 'te) l� tL j2nL� <br /><Applicaltt Names �/ E��'--v-'4?-./'A/C . l�Qn �G A-- Address <br />Busin ss Telephone No. "` Emergency Telephone No. <br />,�N2 <br />IL Property Location/Address �qr� !,l) IFA! lA t� l /���'T T� ✓ .' S '' �,.. _ ['; . ,.. <br />iPropertytOwner ��lll=✓121�v �%S� - -.._ Address �//!,? ��`�!/n11� eq �Inr�! <br />REMIT <br />LOp.erator's Name' 1 i- <br />BASE <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />BILLING <br />❑ AESTAURANT ❑% FOQD RKET RVAIL ❑ FOOP MARKET WHOLESALE ❑ EAT MARKET <br />i, ( i <br />= <br />❑ FOOD PROCESSING PLANT COMMISSARY ICS"RL�4NT -BAKERY <br />CKED <br />"ROADSIDE FOOD STAND ❑ LIQUOR •___= ❑ -BAR - - —_-_ • • --:. Q .ITINERANT RESTAURANT <br />CO,NFECT_IONARY STORE- FOOD,$ALVAGER ❑ FOOD DEMONSTR: TION ❑ FOOD VENDOR <br />DATE <br />,, �._+ :� " " -. ' . ; Q Md9TL'EI0dOD PR 6. UI4IT ❑ �%E DING VE#iIC .E-- <br />❑ VENDING MACHINES/No. oti} <br />REMITTED <br />❑ FOOD CROP HARVESTING/No. of Field Employees — <br />gtylO{;INT <br />ALL APPLICANTS: Total Employees Including Operators <br />2. 'HOUSING{ 7�, •. {... t <br />❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑WATER-S"AM`PLE (Bacterial)' Or (I:HrzmlQAI_ I ` <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER r <br />Id <br />NO. OF` PUBLICISEI�VED (Conhectiona) `"` <br />' <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA d WAD' , ( NAT L BATHING PACE <br />rf G �% <br />t <br />5. VECTOR CONTROL 11 POULTRY FARM/Maximum No. of Birds " <br />;ENNEL/Runways /Animal Population No. No. of Confining Cagesa <br />Sewage Disposal Method <br />Solid Waste Disposal Method <br />r <br />Water Supply Source __ Animal Waste Disposal Method <br />6. 13 CONSULTATION FEE <br />�CYI Ey✓C(,�r`�?� /\1 ST�L(�$/S� �i9/1/� <br />7. d!J 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 ` ""Sealer 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 0"G1 -�,�1" Title C'il• r. lr.�• �' Date,��i&2f <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 & Received By January 31 ❑July 1 &Received By July 3T <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT. DUE <br />CKED <br />DATE <br />DATE <br />REMITTED <br />gtylO{;INT <br />FEE <br />LESS <br />3: hours <br />✓ <br />r <br />,PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Receive -15 Date ceipt No. Permit No. II.We Date Mailed Delivered <br />AYYLIUAN 1—MC I UMN ALL VVrIG.i �v. c.�•.nvmc.••.r•r.••�••�•... �......., ��....��� ___. _. ...._____ _-_-.-_... - <br />