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Applketlone WIII Ba geaad Who"Submitted properly Completed.Be S o Sign The Application. <br /> SAN JOAQUIN LOCAL HEALTH DIST GENERAL <br /> ENGINEERS AND/OR APPLICATION IF VEHICLE INVOLVED,GIVE <br /> APPL ICANT'S AND/ORMake --- <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMITlSERVICES Lid. No. — <br /> 1 BROKER AND/OR <br /> LICENSE AND/OR PUI ESTOOL&WATERS,AMBLING Regist.No. <br /> REGISTRATION RELIES TATER OATEN LAPIRUNS <br /> VEIL ESTATE INLPECTiONL Color <br /> NUMBER POULTRY RANCHES AND KENNUS <br /> 2 O MISCELLANEOUS SERVICES ^I. <br /> 'Application Date �!I'".�.'8,u[sine /Nam �Appe/ISOn��m� 1� [ <br /> Type Perm t/Service ROCIy sled,� <br /> rpplicant Name <br /> �✓/l9d � Ce&Ie Address <br /> # _ usiness Tel h vNO. _ 2� U Emergency Telephone No. <br /> S Property LocatioN dress 1 Z L ' <br /> Property Owner Address ✓ 0-0c `-- <br /> L 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 /> A. RECREATIONAL HEALTH ❑ SWIMMING POOL 13 SP <br /> 13 WADING POOL ❑ NATURAL BATHING PLACE _ <br /> 5. VEC-,OR CONTROL ❑ POULTRY FARM/Maximum No.of Birds ' <br /> ❑ KENNELJRunwaya _ /Animal Population NO. No.of Confining Cages <br /> SevyaCo nisposal Method <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 /> D. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company — <br /> Sewage System Inspection ❑ Address— _Tele.No. <br /> Escrow No. <br /> Seller _ Seiler 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,a ru a g lations the n Joaquin Local Health District <br /> APPLICANTS SIGNATURE X Tltle- /,-Z� Date -5-- 23-,!5?6 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DUs: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J..,1 A Recalvad By January 31 ❑July 1 a Reeeived By Jury 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE L AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE l o II v <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> Y , OTHER <br /> 7 <br /> OTHER <br /> e <br /> Rneived by Data Roceipt No. Permit Na. Im.ame Date Mailed Delivered t <br /> APPLICANT—RETLaIIALL.0 IDaTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1e01 E.INZELTON AVE.,P.O.Bea 300E eTOCKTON,CA eS2M W <br />