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Applications Will 0*ssed When Submitted Properly Completed, B*To Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No <br /> IrFNSE AND/OR PO --- --- -- ---. <br /> ULTRY RANCHES AND KENNELS - <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No <br /> I. .BER <br /> r~ Color __.----- ----- __._ <br /> l_ <br /> (Application Date_—___ Business/Name To Appear On Permit <br /> ---� - <br /> FTYPB PBrmiVService Requested: <br /> `Applicant Name —_Pla.i-ns-Bui 1-dexs,_-If1C..—,­_ .__ Address ._-P..__0.--_.BtaX J-0.08,-A[�lcmi- �IL,�_CA _791 L4_ <br /> U <br /> CL — -- ----------- —_-. Business Telephone No.—.� Emergency Telephone No. <br /> A Property Location/Address_---3g07---Car-0r�a-do, _cStkR _ -`--- <br /> Property Owner _-- _---_-�, _-. . 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 /> ❑ 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 — ❑ MOE3ILE 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 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 /> 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. ❑ CONSULTATION FEE KS -- - USTEL38 <br /> 7. ❑ PLAN CHECKING FEE — <br /> 8. 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 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. <br /> APPLICANT'S SIGNATURE X -_ Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE_ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> !1 T-- jogn <br /> 8/22/90�]ry �y AMOUNT <br /> FEE — �10rJ_.VO Ins ecrJ GC 70,-_�( $105.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _�✓ +3 vv <br /> OTHER <br /> OTHER � ---- - -"— <br /> Received by Dale Receipt No Permit No Issu.nce Dale — Mailed Delivered- <br /> APPLICANT—RETIJ R N <br /> eliveredAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />