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Applications Will Be P ssed When Submitted Properly Complrt�"!9, To Sign The Application. <br /> APPLICATION 11-.�' <br /> ENGINEER'S ANOIOR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S ANDiOR F000 ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR PUBLIC <br /> REAL ESTATE INSPECTIONS <br /> FNSE AND/OR LIC. NO. <br /> POULTRY RANCHES ANO KENNELS <br /> I. .AERATION MISCELLANEOUS SERVICES Regist. No. <br /> -- - --- CDIOf ----- <br /> Application Date Business/Name To Appear On Permit <br /> -- <br /> F TypePermit/Ser vs Requeste -------_- <br /> -.. . <br /> /Applicant Name . Address ox <br /> ii — - — - --- - Business Telephone No. --_ —— Emergency Telephone No. <br /> <Pro dress <br /> ----- --- <br /> THIS CHECK 18 DELIVERED FOR PAYMENT <br /> OP ON THE FOLLOWING ACCOUNTS. - <br /> LOP <br /> RICH-MART 10301 <br /> ' <br /> ❑ _ JIM THORPE. DISTRIBUTOR OF QUALITY PRODUCTS <br /> 0 � � _` 368-6175 462-4581 <br /> ❑ ! "- 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> - - LODI. CA 95241-0357 <br /> ❑ -- ---- --- PAY - — 3�re1l— <br /> ❑ TOTAL TO THE <br /> ORDER O �� I <br /> ALI DISCOUNT —J $ <br /> 2. AMOUNT OF CHECK <br /> © DOLLARS <br /> 0 <br /> 3 LODI OFFICE <br /> 120 W.Walnut .,Lodi.CA 95240 <br /> NC <br /> 4. <br /> s. <br /> r :ENNEL/Runways /Animal Population No. , N <br /> Sewage Disposal Method o. of Confining Cages <br /> Solid Waste Disposal Method �— <br /> Water y Source _ Animal Waste Disposal Method — <br /> 6. IZJ CONSULTATION FEE r6A pa" 36, I <br /> 7. ❑ PLAN CHECKING FEE — <br /> R REAL ESTATE �l,�ntJ- <br /> REQUEST: Water Well Inspection❑ Sample❑ Title Cort `, x _ <br /> Sewage System Inspection ❑ Addr, x0�o <br /> Escrow �— <br /> No. — Tele. <br /> Seller - — --- — 1 Addretsl� <br /> Telephone No. Seller Agent Name•'' <br /> Service Request For Date _ �__ — �• �— — <br /> I hereby certify that I have prepared this application and that the Ark 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 w <br /> --- —� Title — Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EH <br /> AC_ ❑ January 1 d Received By January 31 ❑ July 1 3 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> {} -- —— <br /> FEE AMOUNT <br /> � IC-eYi,G�- '�--- - <br /> PLUS _- <br /> PENALTY <br /> OTHER --— - - --- ------— -- -- <br /> OTHER — -- — — <br /> Received by Date <br /> ece,pl No Permit NO ------- <br /> issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.14e 7F1 Tnu <br />