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Applications Will Be Pssed When Submitted Properly Completed. Be Sysfl 7o Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES Ij <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make -------------- -' <br /> APPLICANT'S AND/OR PUBLIC POOLS.WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS LiC. No. ----- ------- -- <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Reglst. NO.------------" <br /> ICRNSE AND/OR MISCELLANEOUS SERVICES <br /> COIOf .- ------- <br /> 3TRATION <br /> I. .BER —... _. <br /> (Application Date- i/«I 40 _ Business/Name To Appear On Permit - -- _ --.- - -- <br /> I <br /> FTYP <br /> e Permit/Service Requested - -� - - 1 J —_—--- <br /> ____ Address <br /> a Applicant Name --5�12�s5�_—_-----"— e.9y_ ry✓—�6$3 Emergency Telephone No. -- <br /> J �A. _ —. Business Tele hone No. k+oN 9sZOS n ' <br /> 9. 973 LooP.,'rs IQ� [e50H1K /KAY S'- Z,E�fa.N C4 93205 <br /> `Property Location/Address— ljyi Address X <br /> a Property Owner FFA /QocL�a LrvlS � 'rR7^/SO ---__��- -- <br /> — Address <br /> 1 Operator's Name . Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> ❑ RESTAURANT 11 FOOD MARKET RETAIL 11 FOOD MARKET WHOLESALE ❑ BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT <br /> ❑ LIQUOR STORE ❑ BAR 11 ITINERANT RESTAURANT <br /> ❑ ROADSIDE FOOD STAND ❑ FOOD DEMONSTRATION 11 FOOD VENDOR <br /> ❑ CONFECTIONARY STOR ❑ FOOD SALVAGER 11 VENDING VEHICLE <br /> ❑ MOBILE FOOD PREP. UNIT <br /> ❑ VENDING MACHINES/No. I - <br /> ❑ FOOD CROP HARVESTING o.of Field Employees — <br /> ALL APPLICANTS. Total Emplo ass Including Operators--- <br /> 2. <br /> —2. HOUSING ❑ CERTIFICATE OF OCCUPANCY PAYMENT HOTEL/MOTEL/No. of Units EV <br /> ❑ MOBILE HOME PARK/No. of Spec — ❑ CHEMICAL RECEIVED <br /> 3. WATER QUALITY ❑ WATER MPLE (Bacterial) <br /> ❑ PUBLIC WATER SYSTEM ❑ SU ACE WATER SUPPLY ❑ WATER HAULER FEB 19 1g91 <br /> NO. OF PUBLIC SERVED (Connections) S;A QUIN COUNTY <br /> 4. RECREATIONAL HEALTH 13SWIMMI POOL 11 SPA ❑ WADING POOL ❑ NATURAL BATENVIRONMENTAL HEALTH IV SIO:'.I <br /> 5. VECTOR CONTROL ❑ POULTRY FA M/Maximum No. of Birds _ <br /> r :ENNEL/Runways __ <br /> /Animal P ulation No. — No. of Confining Cages <br /> Sewage Disposal Method " <br /> Solid Waste Disposal Method <br /> Animal Was Ispp§a ethod <br /> WaterSupplySource —.- t+� �•N. 'a <br /> 6. X+ CONSULTATION FEE 6sT S <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample❑ Title Company Tele. No. <br /> Sewage System Inspection ❑ dress <br /> Escrow No. _ <br /> Seller Sell Address <br /> Telephone No. Seller Agent ame -- <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and t t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> Title Date <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT E ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE IdEACH ❑ J uary 1 &Received By January 31 ❑ July 1 &Receiv REMITuIy 31 <br /> BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER PENALTI S WILL BE A PLIED TOP - <br /> DAYS F OM BILLIN DATE. <br /> OTHER <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Date <br /> Received by 1501 E.HAZELTON AVE.,P. 0.2009 STOCKTON,CA 95201-- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,4 <br />