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Applications Will Be Pror When Submitted Property Completed.Be Sure gn The Application. <br /> APPLICATION a <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S ANO/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR ANO/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. NO. <br /> irENSE ANO/OR POULTRY RANCHES AND KENNELS Re ist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> i. :AER <br /> [Application Date I I'f 3� D Business/Name To Appear On Permit U 1 <br /> rnType Permit/Service Requested: /i _ <br /> Applicant Name �X�7_�C,� `_ Address q)`102z �aS%y C �ez-r <br /> l —fgem n At T <br /> CP -4634 ---31 f L/ Business Telephone No. Emergency Telephone No. <br /> `Property Location/Address_ J`^� �• }-(�'fi /-f� _, 6-D2C l!gM.&J <br /> `Property Owner _ Address <br /> LOperator'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 /> 4. RECREATIONAL HEALTH G SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. 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. M CONSULTATION FEE lei ITN,25Sc-1� SOI t- SPirri4 PLI ki( - Ohl sT)toI L?0 g�f i, 9C `f- ll hg90 U ot)E '. lur-6 i <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection SampleO 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. and rules 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE I REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> Oh <br /> 3 H s vu cx <br /> FE Pu 9PEun c;r! <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> i <br /> Recewod by ^� Date R 2.WNc, Permit No — Issuanc Marled Delivered i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 - <br />