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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER'S AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S ANO/OR <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES Make -- <br /> BROKER ANO/OR LIC. No. <br /> LICENSE AND/OR F000 ESTABLISHMENTS.HOUSING <br /> REGISTRATION PUBLIC POOLS.WATER SAMPLING Regist. NO. <br /> NUMBER REAL ESTATE INSPECTIONS Color <br /> POULTRY RANCHES AND KENNELS <br /> MISCELLANEOUS SERVICES <br /> rApplication Date O Business/Name To Appeaa n Permit <br /> tot Type Permit/Servic equ sted:__ ,/��i/Z__'��l"i°� C/r,( !2G'i SOD.��Ca . ,s �R>x j—Erni' rlNi1 <br /> 3 Applicant Name ti `K Address 44-- <br /> Business Telephone No. EmergencyT lephone No. <br /> Property Location/Address ��i¢rr�/ �`iri� �caLci <br /> Property Owner✓a /3r c.i/GJ ,3611' GGO/ Address <br /> L Operator's Named/•-L-, .r/i .tv.c./Address <br /> 1. FOOD ESTABLISHMENT Total Building Sq. Footage Restaurant,eklmum 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 V � I /J <br /> 3. WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL � ,f,^ffat <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER {d A--, <br /> v1 ��"1 O " <br /> NO. OF PUBLIC SERVED (Connections) - '"Q <br /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE. <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds B7(WY A//_- qkkZ//"^^"T` <br /> ❑ KENNEVRunways /Animal Population No. _ No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source ty Animal Waste Disposal Method <br /> S. i CONSULTATION FIE lA� ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> B. 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 rul!"nd regulations of San Joaquin Local Health District. <br /> i� <br /> APPLICANTS SIGNATURE X _ Title��Gt P ) Date (dam•'�� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DUO.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITi ANCE S ED REMIT <br /> BASE EXPLANATION DATE DATE REMITTAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S, C).7. 1 DLESSO <br /> PRORATION (//•' <br /> PLUG <br /> PENALTY <br /> OTHER <br /> 'v <br /> OTHER <br /> Received by Date Receipt No. Permll No. louanee Dap Mallad Delivered 9 <br /> APPLICANT—RETUBMALL.COML/TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES leer!.MAZILTON AVl..P.O.ae.saes STOCKTOW CA wasv 6 <br />