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E~ONMENTAL HEALTH PERMIT/SERVICaW <br /> ENGINEER'S ANO 09 IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S ANDrOR FOOD ESTABLISHMENTS. MOUSING Make <br /> CONTRACTOR ANDIOR PUBLIC POOLS.WATER SAMPLING -- -- <br /> BROKER ANMOR REAL ESTATE INSPECTIONS LIC. NO. - <br /> IrFNSE AND OR POULTRY RANCHES AND KENNELS Re ISI. NO. <br /> ;TRATION MISCELLANEOUS SERVICES g --- <br /> dER Color <br /> Application Date 9-2�a.ff _. ._ Business/Name To Appear On Permit - <br /> oType PermiVServicRequestetl _-_ - <br /> iAppp�ppllsica'ntName `TIE1L�lj mgr _�5`-wc,- _ Address 135.E Wi L-DA) LOW -S4 i09 _- <br /> u Business Telephon o .. -- _. . Emergency Telephone No. - <br /> J -_ <br /> i55 W I�Luru�G Property Location/Address 4 <br /> iProperty Owner - �l�t/Eyi�Sa_t-r-vD - Address <br /> IOperator's Name _ _ Z_ ��_—_—_— _--- - 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 ❑ LIOUOR 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 /> J. WATER QUALITY ❑ WATER SAMPLE (Bacterial ❑ CHEMICAL F <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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No-of Birds <br /> F :ENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water <br /> Supply Source Ani aKWaste Disposal Method <br /> 6. CONSULTATION FEE L'CU �� u•iLJR''E� F �`�/ <br /> 7. PLAN CHECKING FEE- -- '_. -- ----.-- <br /> 4. REAL ESTATE <br /> REOUEST'. 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 1 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 11PER 817E C1EACH ❑ January 18 Received By January 31 ❑ July 1 A Received By July 31 <br /> --- — __ <br /> S REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �••AQ rVV — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _— — — JL�r� Z'OVI •ZJ <br /> ed by Dale Recelpt No Parmd No IsauanG!DOM AFailad Delivered <br /> cPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERWT/SERVICES 1501 E.""ELTON AVE,P.O.ew 2099 STOCKTON.CA 952111 <br />