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Applications Will Be P, :sed When Submitted Properly Completed. Be S To Sign The Application. <br /> APPLICATION <br /> �-KVIRONMENTAL HEALTH PERMIT/SERVI,;iS <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.NOUSvVik-t <br /> Make ._ <br /> CONTRACTOR AND/OR PUBLIC POOLS WATER SAMPLI - _--' <br /> BROKER AND/OR REAL ESTATE INSPECTIONSLic. NO. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNRegist. No._ <br /> STRATION MISCELLANEOUS SERVICESg ---- <br /> I. AER Color _ .. <br /> Application Date . Z (4 q0 __ Business/Name To Appear On Permit — <br /> InType Permit/Service Requested: __ ---Z�Pct+p*u--- <br /> Applicant Name kc tfxr a _. AddresseO. Box SS129 StXN CA 95.tOC' <br /> -- /� <br /> Business Tele h n o ��— `L�'Ft 4991201 Emergency Telephone No. _ <br /> IL Property Location/Address 4. `-n AJ La <br /> Property Owner Address _ <br /> L 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 /> ❑ 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. Cy CONSULTATION FEE S.l Sva. unci ri.+sDe4�lnwr 2S�Ppolar. <br /> T. ❑ PLAN CHECKING FEE _ <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 13 -TitleCompanj',, _ <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 /> I hereby certify that I have prepared this ppiication and that the work wl be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X Date <br /> FOR DEPI,RTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 13 PER UNIT ❑ PER SITE Y—//EACH ❑ January 1 a Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT L' <br /> FEE V- r f/rSuI�nIN �2 /U <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rz <br /> Received by Date Receipt No. Permil No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201— <br />