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II <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> EP _.riO� L4���A( (�� f;13kC�_ GEi�tf2AL <br /> ENGINEER'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 /> LICENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> REGISTRATION MISCELLANEOUS SERVICES <br /> Color <br /> NUMBER FEE Is <br /> DUE WITH APPLICATION BEFORE DUE DATE AS SHOWN BELOW <br /> [Application Date Business/Name To Appear On Permit ArOS Boarding Kennel <br /> Type Permit/Service Requested: <br /> QApplicantName Arnc Rnarriinn Kannel _ Address 2115 Albert Ct. , Tracy <br /> U Business Telephone No. Emergency Telephone No. <br /> 0. <br /> a Property Location/Address 2115 Albert Court, Tracy _ __ — <br /> aProperty Owner Address - <br /> I 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 /> 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 /> 11 KENNEL/Runwas /Animal P -io No. _ _ _ No. of Confining Cages ___ 1l <br /> Sewage Disposal Method � z <br /> Solid Waste Disposal Method <br /> Water Supply Source _ Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE ❑ BUSINESS LICENSE - <br /> 7. ❑ PLAN CHECKING FEE - ❑ DANCE PERMIT <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ SampleO 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, anLiles and reg a i ns a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE TitIe�� � Date/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Q ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH X3 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $35.00 1982 1/1/82 Due 1/31/82 $35.00j' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY II I RP ADDED AFTER D 11 <br /> OTHER 30 DAYS-5076 of BASE FEE <br /> OTHER 60 DAYS- /O O <br /> 90 t 6 6 <br /> SE FEE <br /> ,s <br /> Received by Clate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />