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Applications Will Be Prod When Submitted Properly Completed. Be Su Sign The Application. SCS/-"�(� `/J <br /> APPLICATION ill <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS. HOUSING Make — <br /> CONTRACTOR AND/OR PUBLIC POOLS. WATER SAMPLING - ----- -- <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Llc. NO. <br /> Ir'.ENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> 3TRATION MISCELLANEOUS SERVICES g -------_ <br /> I. .BER _...._- __. _-.. Color <br /> Application Date—(�/b _QO Business/Name To Appear On Permit <br /> �Type Permit/Service Requested: SOAJ SQnnpTTrx, INspec-�'ra>•+ ___ <br /> T— <br /> `Applicant Name SQt�.— __ Address x/31 W /7/ cItiQa.I <br /> -/1'�°°/Ps-{o CA' _ Business Tele hone No.—�Q9 52A/-9653 <br /> e. i p Emergency Telephone No. _ <br /> '<Property Location/Address.;Z973 Lac is 1i sfae k-�o... _ 952OT" <br /> Property Owner�c��oc�w LrvPs�vek -flp�sgw/t'fieN (n _ Address_ART�!3 d56i i iQc.� S"�xkfo/v 04 17S.20S <br /> LOperator'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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEURunways — /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> WaterSupplySource Animal Waste Disposal Method <br /> 6. Y1 LONSULTATION FEE ST Soil ��'A mP(IAJO /n.^peC�7yN <br /> 7. ❑ .PLAN CHECKING FEE J <br /> 8. 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. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 13 ANNUALLY EI PER UNIT ❑ PER SITE f/J EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE OUN DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �3,BO 5'S r r IIIIL6191 <br /> LESS <br /> PRORATION <br /> PLUS 11 <br /> PENALTY <br /> OTHER PENAL" S UV!LL SE?, PL.!'D iO ryMAM <br /> OTHER JAYS FI ON! B11LL11-N 9 DA 71 - — <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON.CA 95201 <br />