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Applications Will Be Prom<sed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERV17`�ES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AtAP/OR FOOD ESTABLISHMENTS. HOUSING Make <br /> CONTRACT AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKE D/OR REAL ESTATE INSPECTIONS Lic. No. <br /> irPNSE AND/OR POULTRY RANCHES AND KENNELS Re ISI. NO. <br /> 3TRATION MISCELLANEOUS SERVICES g <br /> I. .aER Color <br /> f Application Date Business/Name To Appear On Permit SEMCD _ <br /> wType Permit/Service Requested: <br /> i Applicant Name SEMCO Address 431 W. Hatch Rd . . Modesto CA 95351 <br /> v <br /> Business Telephone No. 524-9653 Emergency Telephone No. <br /> (Property Location/Address 24155 S Corral Hollow Road Tracy CA <br /> `Property Owner State of California Address <br /> Operator's Name Calif/Dept of TranSDOTtation Address 1976 E . Charter Way Stockton <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 /> WaterSupply Source Animal Waste Disposal Method <br /> B. X_CONSULTATION FEE 9DIy {.ZIA7[� AiJlt� ./I.E3zl6- J <br /> T. ❑ PLAN CHECKING FEE <br /> B. 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 la an rules anAnd r guI ti ns of thin San Joaquin Local Health istrict <br /> APPLICANT'S SIGNATURE X' ` Title Date <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja ry 1 S Receiv By January 31 ❑ July 1 A,Received By July 31 <br /> REMIT <br /> BILLING REMITT CE s <br /> ED <br /> BASE EXPLANATION DATE DAT <br /> REMI AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> QyeCd <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER aW <br /> OTHER <br /> r4lid by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 18101 E.HAZELTON AVE.,P.O.Boa 2008 STOCKTON,CA 9620 <br />