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Applications Will Be Pr,--+ssed When Submitted Properly Completed. Be Su- ign The Application. <br /> ( APPLICATION <br /> EN IRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND;OR <br /> APPLICANT'S ANDIOR F000 ESTABLISHMENTS.HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS <br /> Lic. No. <br /> .DENSE AND/OR POULTRY RANCHES AND KENNELS <br /> ;TRATION MISCELLANEouS SERVICES Regist. No. <br /> I. .dER _.. Color <br /> Application Datell�_rf 0 Business/Name To Appear On Permit <br /> oType Permit/Service Requested: <br /> UApplicant Name �_EN&i r3an2_4�r Address�•O, FxZic <br /> Business Telephone No. Emergency Telephone No. <br /> `Property Location/Address 3559 LQ H1'1Mt='?- L-Prlug . 7;,70Cf-eiTa+,,j <br /> a Property Owner Address <br /> Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ ,FOOD MARKET WHOLESALE E3 MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR 13 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 /> r :ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source _. Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> T. P(.PLAN CHECKING FEE �>✓VIEyV`� pIPll�tr Rt=_PtR�EMeT�IT �LRnIS. SECI�1UUf��2� �'n,uTAlrJ M^I.1T"pfAti1� <br /> 8. REAL ESTATE `�" TA1Uk �tpdWL 1�c A-tuS �� FOQt��� Pr=�tolr4� INSP�"f�Or+I$ <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 1 have prepared this apolication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg ul ions 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 UNITJE3PER SITE ❑ EACH ❑ January 1 8 Received By January 31 C1July 1 &Received By July 31 <br /> Fee Is Due: C1 ANNUALLY [:1 PER UNIT <br /> REMIT <br /> BASE (EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE 7� REMITTED AMOUNT_ <br /> FEE H2_ ia�ga .LP r1� 'S4 <br /> LESS f` jk)&-'gf:PLA ?L,4rN <br /> PRORATION 'JBM,Rb-70n"aj—I `f'q/1t 1 Cjc <br /> PLUS1 3s�+�, � etsK. <br /> PENALTY ��"�I'1f..1r7PEGTIGNS )Df i-_d"ro 1 <br /> OTHER R M4 r 5:TU mm no td 9G <br /> OTHER <br /> Received by Date t No. Permit No Issu ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVI ENTAL HEALTH PERMIT/SERVICES 1601 E.HAZL .N AVE.,P.O.Bo:2009 STOCKTON.CA 45201 <br />