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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. N Cw'L/ 2 , <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ,NEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> JLICANT'S AND/OR F000 ESTABLISHMENTS.HOUSING Make <br /> ONTRACTOR AND/OR PUBLIC POOLS WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Llc. No. — <br /> irENSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES Regist. NO. <br /> I, .BER Color <br /> [Application Date-ICAO. /3. �/O / ne1ss/Name To Appear On Permit mc,4A✓en En✓'ros,Au i / y r yJ>. <br /> :Type Permit/Service Requested: CrS..ru/to TiBx Ap 0902 reV;e La ff <br /> zA plicant Name ✓e Adtlr ss ///D/ l�lii e I�nwc/ <br /> ,moan 1.o CON�e✓a CA gs670 Business 7e a one N / �6314'36 A4 <br /> i Emergency Telephone No. <br /> i Property Location/Address Z / C r 016, <br /> .Je Property owner n c_. Address SDD kilZer At/elrUe. /Ue J/o//w .� PA <br /> Operator's Name o �+ a Address /-z r <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 n <br /> 2. HOUSING ,` <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces \� <br /> 3. WATER QUALITY ❑ 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 /> r5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> t KENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste DisposLMethod J� <br /> 6, CONSULTATION FEE �_ �3S /Wur 041^ I"P�or/ re✓i0W Si t_ /�o-a.VisP 'R. <br /> 7. ❑ PLAN CHECKING FEE <br /> Ii. 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 /> 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,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X I Title Su/�j4E91-0-';Date /-3 g <br /> Ll FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan„ary 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE AMOUNT <br /> PAYMt:. III <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS FEB I b IM <br /> PENALTY <br /> OTHER <br /> OTHER PER UT/SERVI ES <br /> i t sI '.)— -76x35. �R <br /> Received by Data ,e eipt No. Permit No. I ` r Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTONAVIS..P.O.Sate SOON STOCKTON,CA 9510 <br />