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Applications Will Be Pr--�ssed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> w APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> %.- NGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. NO. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. NO. <br /> L .dER Color <br /> [Application Date Business/Name To Appear On Permit <br /> Type Permit/Service REtquested: n ` <br /> Applicant Name K tY'HQQY L Address p/� AVon Dr. <br /> iL <br /> =I)Telephone No.;r Emergency Telephone No. <br /> g Property Location/Address <br /> Property Ownerik 4r4l tb—v✓L da j:zj Address <br /> 10perator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restatftnt, 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 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 __ rgmmal Waste Disposal Method _ <br /> 6. CONSULTATION FEE QVI&A-) EI t 4n— 'tMAtooIMA <br /> T. ❑ .PLAN CHECKING FEE <br /> S. 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, an rules and re tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title ate 3-9-f�9 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A eceived By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE ITTED AMO DUE CHECKED <br /> 2` LL AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER Is'- k <br /> OTHER <br /> 3 <br /> ved by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Sox 21109 STOCKTON.CA 95201 <br />