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Applications Will Be Prc -ed When Submitted Properly Completed. Be Su -o Sign The Application. <br /> UGST PROGRAM APPLICATION 1' •d <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> NGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS.HOUSING Make — <br /> �CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS E.C. No. -- <br /> 10ENSE AND/OR POULTRY RANCHES AND KENNELS Regisl. No. —-- <br /> 3TRATION MISCELLANEOUS SERVICES <br /> QO101 <br /> I. .BER _ <br /> 8-27-90 Business/Name To Appear On Permit <br /> f Application Dale PI' -- - <br /> oType Permit/Service Requested:—FILE REVIEW/RL�,,�1tA RF A�yE__ <br /> i Applicant NadcEesS <br /> 4 crlTmn on•J ceY.rme rrr nun , <br /> @IAsiness Telephone No. Emergency Telephone No. <br /> 6 <br /> i Property Location/Address 21ID3 , <br /> iProperty 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 <br /> ❑ LIQUOR STORE —Q-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 -- -- Pe <br /> ALL APPLICANTS: Total Employees Including Operators -- - PAYMENT <br /> MENT <br /> 2. NG <br /> 13HO ESI MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY RECEIVED <br /> ❑ MOBILE HOME PARK/No. of Spaces 9 CT 2 2 1988 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER SAN JOAQUIN COUNTY <br /> NO. OF PUBLIC SERVED (Connections) FN P�URnBNLMIC HEALTH SERVICES <br /> 4. RECREATIONAL HEALTH 11 SWIMMING POOL 13 SPA 11 WADING POOL 11 NATURAL BATHIR'GVPLT.'CEENTAL HEALTH DIVISION <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 - I - <br /> Water Supply Source _ 'Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE - <br /> 7. ❑ PLAN CHECKING FEE <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 /> 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 SIGNAT-URE-X- -- Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 is Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION ,,..@@ILLLIPfU REMITTANCE E AMOUNT DUE CHECKED <br /> 9—LfmTQ10 DATE REMITTED AMOUNT_ <br /> PEE $40.00 FILE REV EW/RECO RELEASE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER `P40 00 <br /> Received by Date V......npt No. Permit No. 1 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 11601 E.HAZELTON AVE.,P.O.Boa 2008 STOCKTON,CA a5ia <br />