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Applications Willt ocessed When Submitted Properly Completed. ure To Sign The Application. <br /> APPLICATION 10 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANTS AND/OR <br /> D/O FOODPUBLIC <br /> C POOLS. <br /> WATERS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> .IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO. <br /> STRATION MISCELLANEOUS SERVICES g <br /> I, ,BER Color <br /> f Application Date Business/Name To Appear On Permit <br /> `II Type Permit/Service Requested: <br /> i Applicant Name SEMC6 Address 431 I+1_ Hatrh Rd. Modesto <br /> uBusiness Telephone No. Emergency Telephone No. <br /> gPropertyLocation/Address 17666 E. Hwy 390, Mtca <br /> `Property Owner Address <br /> Operator'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 /> 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. )a CONSULTATION FEE —Soil Sampling <br /> T. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection IJ 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 ap lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ru es nd regu C ns of the S Joaquin Local Heal District. <br /> APPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE OINILY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING ITTANCE $ REMIT <br /> BASE EXPLANATION DATEREMITTED A U T DUE CHECKED <br /> AMOUNT_ <br /> FEE $192 so 5.5 hrs @ 6/26/89 76.66 L . <br /> LESS <br /> PRORATION <br /> PLUS PENALTY PENALT ES WILL BEA PLIED TO PA3T NTS•V ! - , <br /> T'- <br /> OTHER DAYS F Rom BILLIN <br /> 4ER <br /> by Date Receipt No. Permit No, Issuance Dale Malted Delivered <br /> .ILICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 21109 STOCKTON,CA 95201 <br />