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I0APPLICATION <br /> RONMENTAL HEALTH PERMIT/SERVI <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 L'IC. NO. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regisl. NO. <br /> STRATION MISCELLANEOUS SERVICES Color <br /> I. AER / <br /> (Application Date Business Name T er On Permit `�� rCy `�' z/�-/� " <br /> IMType Permit/Servib uesfedii1"' - - <br /> AV= <br /> Address ,N - L _ <br /> Busin as Tele hone O.� 4!- �� Emergency Telephone No. <br /> Property Location/Address --- B a- <br /> Property Owner1"1`12 Address <br /> .5 d6 <br /> Operator's Name T, r - nil.-Life-4f Address a�3 /9rJy S e S?OG, <br /> 1. FOOD ESTABLISHMENTS Tote 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 DUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL I <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 /> Water Supply Source Animal Waste Disposal Method -- - <br /> 6. PDCONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE - <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample 13 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 pr ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws r es and regulations of thg n Joaquin Local Health District. _/_ 'F <br /> APPLICANT'S SIGNATURE X _—. ' _. / —_—. Title ✓' C e �I�S�CiVi�W Date <br /> __ <br /> FOR DE41PITMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -ER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE E%PLANAT ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -__--__ —_—. • <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fczZA <br /> AWL <br /> Recened by Data tNo. Perm11 No. asu ate Malleo Defi wed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NAL N AVE.,P.O.sea 2888 STOCKTON.CA 6520 <br />