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Applications Will Be P, i When Submitted Properly Completed. Be e ,T'Slgn The Application. <br /> I APPLICATION v9rr/ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/ORIF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR \ PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Gpt�IrENSE ANO/OR POULTRY RANCHES ANO KENNELS3TRATION MISCELLANEOUS SERVICES <br /> aER _._-___..____ ___._._. l / <br /> f Application Date_7 �L� Business/Nam/CI To Ap ear On Permit 4a rrit s 6,i i s 1 ru C. 17'0, <br /> Type Permit/Service R'qu '�-.-/i=- �" <br /> 3 61 <br /> Applicant Name— eC t.i1 C fNU c_t_T LA!S=2_. Address— "�O S ti• (L- S f7^r,tG <br /> _— �t_�� 7D.3 Business Telephone No. Emer enc Telephone Not <br /> i Property Location/A�d/ress ��� - GLS G �'P7_14.5 <br /> "Property Owner "etU JP� S - S_ / __ 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 ❑ MEAT MARKET <br /> r❑ 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 DUALITY ❑ 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. ❑,�, 9pp SULTATION FEE <br /> 7. U1"/PLAN CHECKING FEE 641 S CL,o tli'e:.— 62L'61 2 <br /> 6. REAL ESTATE <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 /> lohereby 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 6 Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE /90 L) —• _ — <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 137 <br /> -.—_ _. ___ _ <br /> Received by Dale Receipt No. Parmil No Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIP`'1NTAL HEALTH PERMIT/SERVICES 1901 E.HAZ' J AVE.,P.O.Bes 20M STOCKTON,CA 951101 - <br />