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Applications Will BeP Vhen Submitted Properly Completed. Be 4*T* n The Application. APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE APPLICANT'S AND/OR FOOD ESTABLISHMENTS, HOUSING Make - CONTRACTOR AND/OR PUBLIC POOLS. WATER SAMPLING (� - - BROKER AND/OR REAL ESTATE INSPECTIONS�L c Lic. No IrENSE AND/OR POULTRY RANCHES AND KENNELS ARC C7� D r STRATTON 412 MISCELLANEOUS SERVICES Regist. No. i. BER __ / Color Application Date _- - Business/Name To Appear On Permit V_tl� ANLL wTypePermit/Service eequest d,:Y,- Z �"v' - � '`if l Address 3%3 Q QNt Cuc�Q., Ica 4.�.r.�� < Applicant Name Business Telephone No6//-5.)q-?0 `o �,o_ Emergency Telephone No. �� 9 v8-�39J a Property Location/Address f�� aProperty Owner Arco - ___ __ __ AddWPNS -.58I p *<_o yg60 L Operator's Name — -- ._-- - _ - - Address - --- - -____--- 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ❑ FOOD CROP HARVESTING/No. of Field Employees ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY ❑ MOBILE HOME PARK/No. of Spaces 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds r ;ENNEL/Runways __ /Animal Population No. _ _- _. No. of Confining Cages --- Sewage Disposal Method - _ -_-__- Solid Waste Disposal Method - -_— - Water Su ply Source Animal Waste Dis osal Method 6. L CONSULTATION FEE SQA �_L-�'S- -1 y I e441 S 7. ❑ PLAN CHECKING FEE 8. REAL ESTATE REQUEST: Water Well Inspection ❑ Sample ❑ Title Company Sewage System Inspection ❑ Address -_ -_ __ Tele. No. _ Escrow No. - -- - - - -- Seller - _ _ _ Seller Address Telephone No. __ _ _ _- Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. APPLICANT'S SIGNATURE X __ _ -_ Title ��oc.� Date �3/g, FOR DEPARTMENT USE ONLY Fnn Ic line f1 eniNi Int I v r7l PFR I INIT ❑ PFR CITF ❑ FA( -,H ❑ .Ianuary 1 & Received By January 31 ❑ July 1 8 Received By July 31 Received by Date ipt No Permit No ISSU, Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Boz 2009 STOCKTON, CA 1s F BASE EXPLANATION BILLING REMITTANCE $REMIT AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE --- `� o 3 �-t- 3.S 7 U LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date ipt No Permit No ISSU, Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Boz 2009 STOCKTON, CA 1s F