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CILLING APPLICATION <br /> _ VIRONMENTAL HEALTH PERMIT/SER Kj S <br /> ENGINEER'S AND/OR QUESTIONS CALL 466-C 7^1 Ext. -4 <br /> APPLICANT'S AND!OR EUOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND,OR PUBLIC POOLS,WATER SAMPLING Maki? <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> LICENSE AND/OR POULTRY RANCHES AND KENNELS <br /> REGISTRATION MISCELLANEOUS SERVICES Regist. No. <br /> NUMBER _—_----- '. <br /> __ <br /> FEE IS DUE '.3ITH APPLICATION BEFORE DUE DATE SHOWN BELOW Color <br /> CApplication Date _- Business/Name To Appear On Permit _AS-BUarAiMIl dQL____ <br /> ,,Type Permit/Service Requested: <br /> Applicant Name___- -Zoardi49_ Ai1e1 Address 21 A b t Court, Tracy <br /> Business Telephone No._ ..____ _- Emergency Telephone No. <br /> art Co <br /> a Property Owner ion/A Susan AroS ---- -- - -- __ -Address ---- - - -- -- <br /> Operator's Name_- - - - Address same a <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 0 FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of - ❑ MOBILE FOOD PREP, UNIT ElVENDING 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/Ne. of Spaces <br /> 3. WATER OUA!_ITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPI_Y ❑ 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 /> 12 KENNEL/Runways _ j__XnSide/Animal Population No. _ __ NO.Of Confining Cages 4 outside rumfays <br /> Sewage Disposal Method _SehtiC_SyStC.PI <br /> Solid Waste Disposal Method -coy pred-ne_j� E_-t tp Spnta;ners -- --- <br /> Water Supply Source pyr�11- Animal Waste Disposal Method <br /> 6. 11 CONSULTATION FEE ❑ BUSINESS LICENSE <br /> 7. ❑ PLAN CHECKING FEE _--_ ❑ DANCE PERMIT <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 r <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 rul s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH _❑ January 1 S Received By January 31 ❑ ,lady 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $35.00 1981 5/13/81 DUe 6/13/81 <br /> LESS - —- —-- — -- - <br /> PRORATION <br /> PLUS <br /> PENALTY P_ENALT -F-AD ED AFTER DUE DATE AS HOWN BELOW <br /> OTHER 30 DAYS 506 of DA E FEE <br /> OTHER o ��ppYJ - <br /> —u <br /> H.�erved by DateReceipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE..P.O.Bat 2009 STOCKTON,CA 95201 <br /> vi <br />