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Applications Will Be r� +ssed When Submitted Properly Completed. Bee To Sign The Application. <br /> APPLICATION <br /> ENGINEER'S ANDiOR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND,OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR ANDIOR PUBLIC POOLS.WATER SAMPLING Make _ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lit. No. <br /> 3TR <br /> 'E AND/OR POULTNT RANCHES AND KENNELS <br /> iTR <br /> ATION MISCELLANEOUS SERVICES Regist. No <br /> .BER _ Color <br /> k(Application Date 1 - 3 Business/Name To A A C <br /> II II Appear On Permit � � 6-4 AC.Q, -r(Z0(�1. <br /> I,krType Permit/Service Requested: <br /> Applicant Name -v--�1 -- S 7 1J 1-� G 11-L-____ Address .Ur& P 1 V OCC2- V31 „¢ <br /> Business Telephone No._ _ Emergency Telephone No <br /> 5tProperty Location/Address nSLJo W i k _gT- 7-t-Lgc,�, C� <br /> i Property Owner_ C'IA 1Q-L, 1L�A U A.EAQr_,_ ___ Address ej7.5 C j auliizo rr�R.Bt�.l L'•L. <br /> i tOperator's Name Address SoS 'PI"li 1160'6 t4 r2 L. . L C w <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 <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces �'",�,,',,' /' /� p _ // <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL '�7 i� �r(/C t i7v� <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HA LER <br /> NO. OF PUBLIC SERVED <br /> nn "yam% O'O /l 41/ <br /> 4. RECREATIONAL HEALTH <br /> � USWIMMING POOL 13 SPA 13 WADING POOL 13 NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - <br /> r :ENNEURunways /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 /> 8. ❑ CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection❑ Semple❑ 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. <br /> APPLICANTS SIGNATURE X a aj�e Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee 19 DUO: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Recene nuary 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> GAGE EXPLANATION DATE DATE EMITTED AMOUNT DUE CHECKED <br /> 1� AMOUNT <br /> e <br /> FEE w �c/wLLS I �/3 •0 �. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTH R 1 <br /> 'Itince"ed by p e Allepikeof No Permit No 150144MO Date Mailed Dalivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 445 N. Sol JPe9u1R St. P.O.Boa 21109 STOCKTON.CA 55201— <br />