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.sa�,.,r� i,:fs'sTu�ss*+c�+�.�e�4,r•i'�"OPsw'®a•s <br />Applications Will Be Posed When Submitted Properly Completed. Be *To Sign The Application. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ENGINEER' -}AND/OR <br />APPLICANT'S AND/OR <br />COF4TRACTOR AND/OR <br />BROKER AND/OR <br />DENSE AND/OR <br />3TRAT N <br />I. .BER` <br />FOOD ESTABLISHMENTS, HOUSING <br />PUBLIC POOLS, WATER SAMPLING <br />REAL ESTATE INSPECTIONS <br />POULTRY RANCHES AND KENNELS <br />MISCELLANEOUS SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. <br />Color <br />[Application Date Business/Name To Appear On Permit L�(RUIt� ('_01.1<ii1LlC TlC �1 ikIL, <br />oType Permit/Service Requested:LLU' t_i"I 'j' C11��>T' <br />QApplicant Name' Address I0S� <J Li ",'(l] L -,-\a- ,_'�L\ <br />_ Busi ess Telephone No, <br />21--1 ps'pEmergency Telephone No. � -� Y� <br />a Property Location/Address �1 'r sy I � BIZ F�4lMt �1C� LzL' ,��TDL� ; OK <br />a Property Owner �`�{ C? lit-Tzol f Address �� i3U� �31 1 I 1t� ML\'T D, r�� HCl Gly <br />jOperator's Name POE- 73,E Address 1 12 1-1 L <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) <br />4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ 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. ❑ CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />8. 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 />y <br />APPLICANT'S SIGNATURE X"ALi - L _ _. Title WXL(F. U [ JOiLl�lr�f� i'"G i Date `"o' -D I �-- 9 <br />77 FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ my 1 8 Receive By July 31 <br />MIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUN DUE C CKED <br />DATE <br />DATE <br />REMITTED <br />OUNT <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 />