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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />E*11IRONMENTAL HEAL TH " RMIT/SERVICES <br />IF VEHICLE INVOLVED, GIVE <br />ENGINEER'S AND/OR FOOD ESTABLISH IS <br />APPLICANT'S AND/OR I6 Make <br />CONTRACTOR AND/OR PUBLIC POOLS <br />REAL ESTATE INN! .NO:•: LiC. No. <br />BROKER AND/OR POULTRY RANChta AAO 31;o, AS <br />IrENSE AND/ORRegist. No. <br />3TRATION MISCELLANEOUS SERVICES - Color <br />.8ER — - -- -- -- _ <br />u Application Date _.� - 3—� g Business/Name To Appear On Permit -Al" C' !S <br />Type Permit/Service Requested: 'SvdY /�"14S <br />l/�Sl Y/ rluC Address!I���Iv�12 /'� <br />Applicant Name ati�vde /SSD <br />-- <br />_ Business Telephone No. ���5 5' -`� h�1 / Emergency 'Telephone No. <br />i 7C/ Pl SroC%fU <br />Property Location/Address 1-- b'( cJ <br />li j" / {j l�4 �LX <br />Property Owner __��1'Y1-'=� _GX,C�S __ Address —If <br />Operator's Name Lt.` —t✓ t' 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 />0 MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) 13 CHEMICAL <br />CJ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO. OF PUBLIC SERVED (Connections) <br />a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />:ENNEL/Runways — /Animal Population No. No. of Confining Cages <br />Sewage Disposal Method <br />J <br />Nater Supply Source Animal Waste Disposal Method <br />S. ❑ CONSULTATION FEE <br />7. ❑ PLAN CHECKING FEE <br />a. REAL ESTATE <br />REQUEST: Water Well Inspection Sample❑ Title Company <br />Sewage System Inspection ❑ Address Tete. 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 application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, an rules and to ulations of the San Joaquin Local Health District, <br />APPLICANT'S SIGNATURE X / d l i �' Title / ` a1 Date / <br />f G `�( v' G 1u' <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 E Received By January 31 ❑ July 1 6 Received By July 31 <br />REMIT <br />BILLING REMITTANCE S <br />BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br />AMOUNT <br />— <br />Cx-) <br />L <br />Z--' <br />3-�`' <br />--7 <br />/ .3 <br />i <br />i <br />- <br />FEE <br />✓•�' <br />✓'aJ <br />LESS <br />(. <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />/-x'07 <br />'ed by Date Receipt No. Permit No. Issuance Date Mailed <br />u RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E. HAZELTON AYE., P.O. Boa 2110111 <br />Delivered <br />STOCKTON. CA fi20 _ <br />