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• Applications Will Beceased When Submitted Properly Completed. Br To Sign The Application. <br /> � � APPLICATION _ <br /> Ei1VIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGIN CR'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APpL7 ANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make - <br /> CONTRACTOR AND/Oil �, - PUBLIC POOLS.WATER SAMPLING <br /> lBROKER AND/OR DEC 5 ;�� REAL ESTATE 1K3PECTIONS -� ` Lit. No. _ --- <br /> Ir-ENSE ANO/OR POULTRY RANCHES AND KENNELS /, t'�, a0t. No. <br /> jTRATION p <br /> MISCELLANEOUS SERVICES <! 1� <br /> I. aER - _ s.pem� <br /> [Application Date _�lL.l�l �• Business/Name To Appear 1)n Permit <br /> Type Permit/Service Requested: - <br /> Applicant Name� 'G�hs--- ` kl ' ddress �i --- <br /> _—=1-�7��� usiinne s Telephone No.7-— Emer y - phone No. <br /> '<Property Location/A dress.-� _-Al. D I s �TG� <br /> j Property Owner TMAKET <br /> -- Address)Operator's Name ,'J'``A' - Address <br /> 1. FOOD ESTABLISHMENTSl Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANSSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STANDR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ F\AAaGoErFER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No.of __._ ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of FiALL APPLICANTS: Total Employees Incrs2. HOUSING❑ HOTEL/MOTEL/No. of Units RTIF ATE OF OCCUPANCY❑ MOBILE HOME PARK/No.of Spaces <br /> 3.' WATER QUALITY ❑ WATER Srial) ❑ CliRMIC <br /> ❑ PUBLIC WATER SYSTEM ❑ SUSUPPLY WA R ULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 0. RECREATIONAL HEALTH ❑ SWIMMING POOL 0 SPA ❑ WADING L ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximun\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 Animal Wast Disposal Method <br /> S. ❑ CONSULTATION FEE Add. S <br /> T. ❑ PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REOUEST: Water Well Inspection[] Sample❑ Title Com ny _ <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 /> e l hereby certify that I have prepared this application and t7,C the rk will be done In accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sen:Daquin cal Health District. <br /> APPLICANT'S SIGNATURE X la <br /> Date <br /> FOR DEPARTMENT USE ILY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1&Received By January 31 EI July 7 6 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> _. DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE / Q =A <br /> LESS LESS <br /> PRORATION <br /> PLUS <br /> PENALTY TO PAST _ UE ACCOU TS 30 <br /> OTHER DAYS FRO IBILLINGD TE. <br /> OTHERPenalty 11/30/90 <br /> $57.75 <br /> Recelvad by Oete _ <br /> APPLICANT-e[TVRN ALL COPIEa TO: ENVIRONMENTAL HEALTH PERMIT//SERI,:C S <br /> Is`fe Dete Maned Delivered <br /> W 7 E.HA2ELTON AVE..P.O.Bps axis STOCKTON.CA NMS <br />