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0PONMENTAL HEALTH PERMIT/SERVI" <br />ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br />APPLICANTS AND/OR FOOD ESTABLISHMENTS. HOUSING Make <br />CONTRACTOR AND/OR PUBLIC POOLS, WATER SAMPLING (� <br />BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br />IrWFNSE AND/OR POULTRY RANCHES AND KENNELS i <br />3TRATION y �o3 MISCELLANEOUS SERVICES Regist. No <br />1. .8ER - - . -/ _ / , ` Color .. - <br />Application Date -(_/. � ___` Business/Name To Appear On Permit tuea-, ' <br />Type Permit/Service eques d: <br />�����` - - - - - -- --- - -- _ <br />`Applicant Name _ _ � v►a±'l__ ___-_ _-___-__ __ Address -7 3(03 Qt -4k X03 <br />U <br />Business Telephone Noc{L q o .% Emergency Telephone No. 6?ql I YE <br />a Property Location/Address <br />aProperty Owner __Arco - - - - - - -- - Add W!'' _ 58 _-80— 144A Tr o 9 y q00 <br />Operator'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 ❑ 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 />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) CHEMICAL <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 Di s oSal Method <br />6. CONSULTATION FEE W014" 14k*% -1' 'e'_111-ec.IJ �- --------- _ _ --- - ----- - ----.- <br />7. ❑ PLAN CHECKING FEE <br />8. REAL ESTATE <br />REQUEST: Water Well Inspection[] Sample C1 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, and rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X __ _ _ - -_ - _ Title _� Date Q <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUAI I Y n PFR HNIT ❑ PFR SITF ❑ FACH n January 1 R RP .PIVPd Rv January 31 ❑ .LjIv 1 A RP.nP.IvP.d Rv .h,Iv 31 <br />Received by Date` I No Permit No. <br />- APPLICANT—RETURN ALL COPIES TO: ENVIRG.—.41141TAL HEALTH PERMIT/SERVICES <br />Issual to Mailed Delivered <br />1501 E. HAZEL . ,A AVE.. P.O. Bos TOOT STOCKTON, CA <br />/.5 E <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />S <br />AMOUNT DUE <br />CHECKED <br />— DATE <br />DATE <br />REMITTED <br />AMOUNT <br />-1 /�1 G � <br />iJ <br />•'� �'�" � <br />� � �� <br />FEE - -- -- <br />LESS <br />--- <br />- <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date` I No Permit No. <br />- APPLICANT—RETURN ALL COPIES TO: ENVIRG.—.41141TAL HEALTH PERMIT/SERVICES <br />Issual to Mailed Delivered <br />1501 E. HAZEL . ,A AVE.. P.O. Bos TOOT STOCKTON, CA <br />/.5 E <br />