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Applications Will Be Pr +ssed When Submitted Properly Completed. Be S• ,To Sign The Application. <br /> — APPLICATION <br /> ,,i <br /> ❑ l5kEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND <br /> CONTRACTOR AND/OR F000 ESTABLISHMENTS, HOUSING IF VEHICLE INVOLVED, GIVE BROKER AND/OR PUBLIC POOLS. WATER SAMPLING Make —Ir'.E REAL ESTATE INSPECTIONS <br /> TR ATTON AND/OR POULTRY RANCHES AND KENNELS LIC. NO. <br /> 3 <br /> STRMISCELLANEOUS SERVICES <br /> I. SER Regist. No. <br /> n p a Color <br /> [Application Date C���p a Business/Name To Appear On Permit <br /> MType Permit/Service Requested: <br /> iA IicantName V 'Rohl UC. Address_ �•'U• /_�A-29 <br /> Business Telehone N <br /> Property Location/ dress 1!J . LO �p r Emergency Telephone No. <br /> Property Owner V pt& ft*q& 1 r::If- A7 ZOC•}�'� _ <br /> LOperator's Name Address r7 • l2 _ rE_�.a. w <br /> Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT 11 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 q 11t��� <br /> ❑ MOBILE HOME PARK/No. of Spaces 'lr� ,rte, llyl ,1��@,' y1 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL 7/ V� ld "�I111! <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ,> <br /> NO, OF PUBLIC SERVED (Connections) S��kc7 1989 <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL El SPA WADING POOL NATURAL BATHIN <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No.of Confining Cages NT�A+-HEATH <br /> Sewage Disposal Method - 41LIT(SE(ZV <br /> Solid Waste Disposal Method <br /> Water Supply Source __. Animal Waste Disposal Method <br /> 6. CONSULTATION FEE (1./�ST MLtfnLj <br /> 7, PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �1 W l NAL IES WILL BE APPLIED TO PASTIDUFACC <br /> LESS <br /> DAYS ROM BILLIN —DAJE.— <br /> PRORATION _. <br /> PLUS <br /> PENALTY <br /> OTHER G O <br /> OTHER •J <br /> Received by Date ��/"Receipt Permit No. - nice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.w111ELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />