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^• �•� fVVV LOIMYISJgmanle.nuuotnu <br /> CONTRACTOR ANO/On `Ilstr PUPLIC POOLS,WATER SAMPLINC Make - — <br /> BROKER ANO/OR REAL ESTATE INSPECTIONS Lic. No. _ <br /> .IrsNSE ANO/CR POULTRY RANCHES AND KENNELS Re 16t. No. M <br /> STRATION MISCELLANEOUS SERVICES g <br /> Color -.. _ .. <br /> I <br /> Va_%Ir�tion C0tox X ass.. �� ., «. bElV.►�..,= C�tSnr Tv Alivear ut•l rRyrm�lt .�T..0 <br /> lcantNilmn ?"Ll, <br /> . <br /> 4YpyplPernilt/ServicR nested - �*j&4 i7& -WekTAppg K <br /> 4 � ress (i <br /> _ � � lBusiness Telephone No.� elepho <br /> i2F <br /> LProperty Location/Add <br /> Property OwnOddrocc <br /> •TOperator's NameX (aO_ � <br /> '�•1: <br /> N AV <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> n RESTAURANT ❑ root)MA(tl(CT nCTAIL ❑ FOOD MARKS t Yvr1ULrSAt_t ❑ 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 _ _ ❑ CERTIFOF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces H11vq <br /> 3. WA 1 LH DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL F1 �lY�!�3S�1Oa�nN3 <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULE /`r r <br /> Pio. Or 1�UBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING PO Q NATURAL 13ATH1 LACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maxlmum No. of Birds <br /> r :ENNEURunways ._ /Animal Population No. �A , t <br /> Sewage Disposal Method <br /> Waste Disposal Method <br /> 0 upply Source Animal Waste Disposal Method <br /> 6. hd CONSULTATION FEE _ AQRrA�t . -t CO chi.• <br /> 7. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspectlon❑ 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 aoollcation And that IhA wnrk will ha dOno in nccordonoo with Can Joaquin OLv„ly <br /> ordinances, state laws. and rules and re ulati the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 7 1 _ _„ Title -(�/1 l Date - Q <br /> \ FOR u DEPARTMENT USE ONLY <br /> pe <br /> Fog Is no ❑ AI1nIU1kLI V ❑ rvi UNIT ❑ ncn DN C E) I!A,r: unnuory 6 mece•vea tsy January 31 ❑ July 1 Q Received Dy JWy 31 _ <br /> I —�^ REMIT <br /> l3itIING REMITTANCE ti <br /> BASE EXPLANATION EXPLANATION I AMOUNT'DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE — (- -�. - -• U U <br /> LESS <br /> PRORATION •— ,• _ _, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Heceire-o by Data ReCe•01 No. Permd No Issuance Date Milded Delwered_ <br /> APPLICANT—RETURN ALL COPIED T0: ENVIRONMENTAL HEALTH PERAIIT!SERVICES 11101 E HAIELTON AVE,PC.bog 2M STOCKTON•CA IS201 <br /> TOTAL P . - <br />