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ael�sursTo Sign The Appllaatlon- <br /> APPLICATION,WWilk <br /> IRONMENTAL HEALTH PERMI�/SERFS <br /> EMGI1 EER'S AND,'Oft <br /> CONTRCANT'S AND/OR <br /> CONTRFOOD ESTABLI$HMENTS, NOUSINOI IF VEHICLE INVOLVED, GIVE <br /> ACTOR AND/OR PUBLIC POOL$,WATER SAMPLIND Make <br /> IrE <br /> 13q NS ANDn7R REAL ESTATE INSFECTIONS <br /> A POULTRY RANCHIS AN17 KENNELS I LiC. No. <br /> 3TR <br /> TFRATIOON MISCELLAN9011y SEAYICES I Regist. No. <br /> r Color <br /> AppliCatian Dato <br /> Puslnoss/Name TD Appear On Permit . Verset" Inc--..-.. <br /> InTypePermit/SorviceRequested: PriOrit.V Riov a SSESs� n�Y -.._.- .. . - F <br /> u media t.' <br /> z Applicant Name _James FrantEs. Varcar �8-- <br /> - Address��.mrose_ <br /> iL — -.. _..-- Business Telephone No. ...(916•} 96 :a I2 li .. Errtgrgency Telephone No, <br /> AL <br /> Property Location/Address 2644 A h l e�/. 1�I ,. Stoc ton <br /> 'PropertyOwnor�d.C1f1C Bell Ttr7E[7h011 Address a G � T7 �slg�l anrrCons ruc 1 n r <br /> LOporator's Name J1>`.._.Steu Address37 ���tte11 Box 15 BI <br /> 1. FOOD ESTABLISHMENT$ Total Building Sq. Footage �e Fau'r P Alm <br /> ❑ RESTAURANT C3FOOD MARKET RETAIL ElFOOD MARKET WHOLESALE <br /> ❑ FOOD PROCESSING PLANT G COMMISSARY 0 ICE PLANT BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR I ❑Afl�E TESTA T <br /> ❑ CONF€CTIONARY STORE ❑ FOOD SALVAGER Q FOOD DEMONSTRATION EN❑ FOO IN , <br /> 13 VENDING MACHINES/No. of ❑ MOBILE FOOD F�REP. UNIT 'EQ6]yf�IALO VEHICLE <br /> 13POOD CROP HARVESTING/No. Of Field Employees _ .., I Mir'/ A y <br /> ALL APPLICANTS' Total-Employees Including Operators SERVlCeStrH <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No, of Spaces I ! <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) CHEMICAL I f <br /> ❑ PUBLIC WATER SYSTEM D SURFACE WATER SUPPLY ❑ WATER HAULER I <br /> NO. OF PUBLIC SERVED (Conneotions) !I..- <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA 0 WADING POOL ❑ NATURAL BATHING PLACE t <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds a <br /> .ENNEURunways .;, /Animal Popufation Na, �..�_ No. of Confilning cages_ y <br /> t , <br /> Sewage Disposal Method <br /> i <br /> Solid Waste Disposal Method <br /> water Supply Source — Animal Waste Disposal Method <br /> 8, OXCONSULTATIONFEEWri,.ty r-eyiew nf•,.., j.to e <br /> �- mant, „for. the Pac Ic R <br /> .felI ASh1Py Rn <br /> 7, 11PLAN CHECKING FEE C(Cton F,ariliit'U and the RemeriiAtip1llD1an:lfor the Parifir RP11. Asp ,1p, <br /> 8. REAL ESTATE KX91111 Stockton Facility NE-132) 7644 99MIXY Ashley Road, Stockton, CA <br />` REQUEST: Water Well Inspection❑ Sample❑ Title Company —.. <br /> Sewage System Inspection ❑ Address it t _.._.__ Tele. No. <br /> Escrow No. <br /> Seller _ __._.. . -- Beller Address <br /> Telephone No. ...._ Seller Agent Name <br /> SP(Ocg Request For Dateit <br /> t hereby certify that I have prepared this application and that the work wilt b� done in accordance with San ,loaquln County <br /> ordinances, slate laws, a d rules and regulations of the San Joaquin Local Health District. <br /> RPG No.; 4534 <br /> APPLICANT'S SIGNATURE x _ Title SjDjor lGeohydrQlra <br /> __ l i % <br /> t <br /> FOR DEPARTMENT USE ONLY' <br /> I <br /> , I <br /> Fee is Ou9: l❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JaAuary 3'1R R(-cawed By January 31 ❑ July 1 6 Received By July 31 � <br /> RgMIT <br /> UILLINCI REMITTANCE IST AMQUNTOUE CHECK80 <br /> BASE EXPLANATION <br /> DATE DATE FiEM TTEtS AMOUNT <br /> ...----' 4x� <br /> FEE <br /> LESS ,.._ ._,. _�.., �..• Il <br /> PRORATION 'I <br /> PLUS <br /> PENALTY .. ,,.. <br /> �I <br /> OTHER <br /> OTHER <br /> necerved by Date Receipt No. Permil Na. 11 ls?su nce 6ata Mailed Oelly~ 9�6d �+ <br /> n rtpF4 T,'l•- ryviwilY�Y1RiJTAI WFALTH PrIWIT/OERVICES,.-... 1 D1 8.HALLTON Avg..P,O.Box 2009 STOCKTON,CA,ISM- --» <br /> 0 :J.,. 9t7 :nV Z 68 ` 7 T _ii�H - r) �i 7QFti�T� 0hJ :r�� f II fl i 1,I 1161HA )H^Z ITHT­ AH . <br />