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Applications Will Be Pr ed When Su APPLPProperty CATION Completed Be S Sign The Application. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENGINEERS ANDIOR FOOD ESTABLISHMENTS,HOUSING Make _ -APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPLING Lic. No. -- <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> irENSE AND/OR MISCELLANEOUS SERVICES Color — — <br /> STRATION <br /> BER — <br /> Application Date ILL 27/88 Business/Name To Appear On Permit <br /> L1NOC�L Cor oration <br /> -r(_1i L . <br /> , 7 r, A• California Filed. Suite 650 <br /> Type Permit/Service Requested: Address 17 <br /> gr. Oration <br /> a Applicant Name A' (415),945 7676 _ Emergency Telephone No. <br /> u ,,k CA 6 Business Telephone No. C�1 <br /> CL <br /> Property Location/Address Pacific .venu SLooltLoT° ,,me 35 above <br /> Address <br /> -_'jPropertyOwner Address - - - <br /> toperator's Name - - - e Foota Restaurant, Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. 9 ❑ MEAT MARKET <br /> El RESTAURANT El FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE E-) BAKERY <br /> [I COMMISSARY 11 ICE PLANT <br /> 11 FOOD PROCESSING PLANT ❑ BRR ❑ ITINERANT RESTAURANT <br /> 1:1 ROADSIDE FOOD STAND El LIQUOR STORE ❑ FOOD VENDOR <br /> 13 FOOD SALVAGER 11 FOOD DEMONSTRATION <br /> 1:1 CONFECTIONARY STORE ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ VENDING MACHINES/No. Of -- - -- - - <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees - - - --ALL APPLICANTS: Total Employees including Operators - <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units _ - - <br /> El MOBILE HOME PARK/No. of Spaces -- - - ❑ CHEMICAL <br /> 3. WATER QUALITY 13 WATER SAMPLE (Bacterial) <br /> 11 PUBLIC WATER SYSTEM 11 SURFACE WATER SUPPLY 13 WATER HAULER <br /> NO, OF PUBLIC SERVED (Connections) - - - SPR El WADING POOL El BATHING PLACE <br /> 4. RECREATIONAL HEALTH [I SWIMMING POOL <br /> 11 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - -- - <br /> /Animal Population No. No. of Confining Cages <br /> r .ENNEL/Runways - - <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method - -- Animal Waste Disposai Method <br /> Water Supply Source _- - 1 <br /> • �, �iYtr IIl].11k1Cl+:in <br /> 6. 0 CONSULTATION FEE ' <br /> T. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well inspection❑ Sample❑ Title Company Tele. No. <br /> Sewage System Inspection ❑ Address - - - <br /> Escrow No. - <br /> Seller Address <br /> Seller - _ <br /> Seller Agent Name <br /> Telephone No. — — - <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 taws, and rules and regulations of the San Joaquin Local Health District. <br /> Title - a; r Date <br /> _ -�eg]re� <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Received REMIT <br /> By January 31 July 1 d Received By JOY31 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE RIEWTTED — AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> — Permia No. Issu' to — Mailed Delivered <br /> N° <br /> Received by 1001 E. <br /> HA <br /> N <br /> Date AVE.,P.O.Box 2409 STOCKTON,GA 95241 <br /> ;APPLICANT—RETURN ALL COPIES TO: ENVI NTAL HEALTH PERMIT/SERVICES <br />