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Applications Will Be PBed When Submitted Properly Completed. Be To Sign The Application. <br /> fa APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/ORIF VEHICLE INVOLVED, GIVE <br /> APPLICANTS' AND/OR F000 ESTABLISHMENTS. HOUSING E <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lia. No <br /> WENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. NO. <br /> I. .SER <br /> Color _ _ <br /> Application;Date_J� ..__ Business/Name To Appear On Permit <br /> FType Permit/Service Requested: Sal I_ <br /> a Applicant Name St?w.c 0 Address_AL3/ W. fkY%LT <br /> /god— <br /> a �Psfo Oy -- ) —. Business TeleFhone No. 207- 52�- 653 Emergency Telephone No. <br /> °a Property Location/Address�g73 Laowlis /4r.( sy ak-lci. r4 <br /> a - .__ QSzor <br /> Property'OwnerfAddress '?'73 6O6"l <br /> c 0r. <br /> Operator's Name Address _ <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURA,NT 11 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET F , <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR _.__ ❑,ITINERANT RESTAURANT <br /> 11 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 /> 11PUBLIC WATER SYSTEM 11SURFACE WATER SUPPLY ❑ WATER HAULER L//\ /S J <br /> NO. OF PUBLIC SERVED (Connections)—. <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL 1:1 SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds — <br /> :ENNEL/Runways _ /Animal Population No. __ No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method �— <br /> WaterSupplySource Animal Wasje-Disposal,Method <br /> 6. y� CONSULTATION FEE 7- <br /> 7. <br /> 7. ❑ PLAN CHECKING FEE _ <br /> 6. REAL ESTATE , <br /> '-REQUEST: Water Well Inspection[] Sample❑ \Title Company t _ <br /> Sewage System Inspection ❑ /add ress Tele. No. <br /> Escrow No. -. y <br /> ' <br /> Seller - __. _._. _ Yr_Address <br /> Telephone No. . . _. Seller Agent°1warne <br /> Service Request For Date <br /> I hereby certify that I have prepared this application and th t the work will be done in accordance with San Joaquin.County <br /> ordinances, state laws. <br /> � i <br /> APPLICANT'S SIGNATURE X - ` !I�- t *�°� Title Date <br /> - FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE IQ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE ExPLANATII)N BILLING REMi $ AMOUNT DUE CHECKED <br /> DATE DATE §.v REMITTED AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> — <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> "— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HIELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201— <br />