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Applications Will Be Prot ed When Submitted Properly Completed. Be Sup Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS. HOUSING Make <br /> (AMNTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR HEAL ESTATE INSPECTIONS Lic. No. <br /> -ENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. NO. <br /> L .aER — Color <br /> [Application Date Business/Name To Appear On Permit <br /> NType Permit/Service Requested: <br /> i Applicant Name Roy F. Weston Address 83 I-1. March Lane, Stockton <br /> u <br /> Business Telephone No Emergency Telephone No. <br /> %Property Location/Address 16777 Howland Rd. , Lathrop <br /> d Property Owner J. R. Simplot Address <br /> 10perator's Name 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 ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDII'MAIVIRENT <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees RECEIVED <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING APR 14 193 <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces ENVIRONMENTAL HEALTH <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL PERMIT/SERVICES <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 Animal Waste Disposal Method <br /> S. Kl CONSULTATION FEE Consultation Review-Work Plan <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,a ules and regulati s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Title Dale <br /> FOR DEPART ENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEErs. <br /> tins-irin Irthr 415,189 $105.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PENAL WILL BE AP L!FD TO PAS O DOE ACCO NTS 30 _ <br /> OTHER DAYS_FR M -BILLING <br /> OTHER <br /> Ts`1 )31.13 <br /> Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES lean E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA BSlat <br />