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r • ' Applications Will Be F ssed When Submitted Properly Completed. Be To Sign The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND'OR IF VEHICLE INVOLVED, GIVE APPLICANTS AND/OR FOOD ESTABLISHMENTS. HOUSING Make CONTRACTOR AND,OR PUBLIC POOLS, WATER SAMPLING — BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. F.NSE AND/OR POULTRY RANCHES AND KENNELS 3TRATION MISCELLANEOUS SERVICES Regist. No 13ER — - Color Application Date y h� 9 Z Business/Name To Appear On Permit a Type Permit/Service Requested: 4u'itil�� i Applicant Name pAv�-� ________ __ Address 3bg- -1 -- ..__.__—._ ____ Business Telephone No. __—_—_—_ _ Emergency Telephone No. (16 Ir E`r7l c .4 �l Lid/�IE G©�T' _ �I SZ 41 L) `Property Location/Address _.___._—__/� Property Owner _. �Ei✓✓-�— _ — _ Address �A� 3o f Gy GyiO c 9 5 Z!) [Operator's Name ._--_—__ —_. Address —_ —__ 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPA Y- / ❑ MOBILE HOME PARK/No. of Spaces (— - (f V IC 3 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) C3 CHEMICAL 6 / ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO OF PUBLIC SERVED (Connections) _ 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds —_ --_-- r :ENNEL/Runways ..._ _ _ __--_ /Animal Population No. _ _. No. of Confining Cages Sewage Disposal Method _ Solid Waste Disposal Method Water Supply Source _ _ Animal Waste Disposal Method 6. ❑ CONSULTATION FEE 7. ❑ PLAN CHECKING FEE _ 8. REAL ESTATE REQUEST: Water Well Inspection Sample❑ Title Company Sewage System Inspection ❑ Address Tele. No. Escrow No. Seller Seller Address _ Telephone No. Seller Agent Name Service Request For Date I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws. APPLICANT'S SIGNATURE X Title Date FOR DEPARTMENT USE ONLY Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 ii Received By January 31 ❑ July 1 & Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE ZO iw� LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date �ipl No Permit No Iss� Date Mailed Delivered ' APPLICANT—RETURN ALL COPIES TO: ENVI—OMENTAL HEALTH PERMIT/SERVICES 445 N. San Joaquin St. P.O. Box 2009 STOCKTON, CA 95201