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Applications Will Bed When Submitted Properly Completed, Be Sign The Application.at � APPLICATION EN INEER'S AND/OR ENVIRONMENTAL (HEALTH PERMIT/SERVICES , APICANT'S AND/OR I dttw'TRACTOR ANDIOR FOOD ESTABLISHMENTS.HOUSING 1 IF VEHICLE INVOLVED, GIVE BROKER AND/OR PUBLIC POOLS,WATER SAMPLING I4'ENSE AND1DA REAL ESTATE INSPECTIONS - 3TRATION POULTRY RANCHES AND KENNELS /I n,51Y+ LIC' No, O_ - - I.T .dER MISCELLANEOUS SERVICES 7R� N 9p ` Color _ � �Jrie LTH [Application Date_- l IyIRv-- NM - .�___ Business/Name To Appear On Permit _� /r FTYpe Permit/Service Requested:_ l i t�qEA uApplicant Name -�--Xl -_- Address - -�-- -- - - a - Business Tele hone No.206.3 2C, C aProperty Location/Address--,!/fib Pry - --_ Emergency Telephone No. aProperty Owner Operator's Name _ Address 1. Address FOOD ESTABLISHMENTS - Total ilding 5q. Footage Restaurant, Maximum Seating Capacity ty ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ ` ❑ FOOD PROCESSING PLANT ❑ COMMISSARY [] MEAT MARKET ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ ICE PLANT El BAKERY ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD RVENDOR ANT RESTAURANT ❑ VENDING MACHINES/No. of -- - ❑ FOOD CROP HARVESTING/No. of Field Employees ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE ALL APPLICANTS: Total Employees Including Operators 2. HOUSING ❑ HOTEL/MOTEL/No. of Units ❑ MOBILE HOME PARK/No. of Spaces CERTIFICATE OF OCCUPANCY WA 3. WATER QUALITY ❑ 13 PUBLIC WATER SYSTEM ❑R SAMPLE (Bacterial) 13 CHEMICAL SURFACE WATER SUPPLY ❑ WATER HAULER NO. OF PUBLIC SERVED (Connections) _ 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ 5. VECTOR CONTROL ❑ WADING' POOL ❑ NATURAL BATHING PLACE F POULTRY FARM/Maximum No. of Birds :ENNEL/Runways . _ ___ /Animal Population No. Sewage Disposal Method No. of Confining CgIges Solid Waste Disposal Method - -- Water uPPIY Source [i. CONSULTATION FEE a� Animal Waste Disposal Method _ 7. 0 PLAN CHECKING FETE S. REAL ESTATE REQUEST: Water Well Inspection Sample❑ Title Company Sewage System Inspection ❑ -- "' Address - Escrow No. _ - - -- -- �,-�Tele. No. Seller - - -- Seller Address Telephone No. Seller Agent Name Service Request For Date I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws. APPLICANT'S SIGNATURE X -- - - ---- - Title _ - - Date _ FOR DZCH TMENT USE ONLY I Fee Is Due: © PER SITE ANNUALLY ❑ PEA UNIT © ❑ January I &Received By January 37 I ❑ July 9 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED FEE �CdD ( AMOUNT_ LESS PRORATION) PLUS PENALTY OTHER j OTHER �y 31 I — ®Ica] I ccf i/ Q'17IAA Received by Datei —- No Permit No -- -- - APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES pis e40 Mailed Delivered 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _.