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Applications Will Be Prod When Submitted Properly Completed. Be Su0 Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONlN3ACTDR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic NO. - - - <br /> Ir'FNSE AND/OR POULTRY RANCHES AND FENNELS Reg ist. No. -- -- <br /> 3TRATION MISCELLANEOUS SERVICES <br /> Color - - <br /> I, dER ---- <br /> (Application Date _ Business/Name To Appear On Permit - <br /> oType Permit/Service Requests : - <br /> a Applicant Name + Address r ' �+ - <br /> B�,nessTelepho�Nor?C Emergency Telephone No. <br /> aProperty Location/AddressA- <br /> -_'j <br /> - <br /> d Property Owner '--. \ 1 - - Address p. o, 1�L'7C �'�(L J�C�' C4 Q q <br /> L <br /> Address <br /> Operator's Name - - - - <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> El RESTAURANT ❑ FOOD MARKET RETAIL 11 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 /> :ENNEL/Runways _ /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method - <br /> Solid Waste Disposal Method <br /> Water ly Source _-_ <br /> ,SAnimal Waste Disposal Method <br /> Wat --- <br /> 6. LAS CONSULTATION FEE -- �A���y <br /> 7. Q PLAN CHECKING FEE <br /> B. REAL ESTATE RECE1VED <br /> REQUEST: Water Well Inspection[] Sample❑ Title Company [1 - -- <br /> Sewage System Inspection ❑ Address _. IAN 2-9_1998 No. _ <br /> Escrow No. SAN JIOAQUIN 0,0LINtilY <br /> Seller Seller Address _ PI IRI 1C HEM T:-' ,�cnVICFS <br /> Telephone No. Seller Agent Name __ ENVIRONMENTAL 1'L;,_I-• DIVISION <br /> Service Request For Date <br /> I hereby certify that the work will be doapiance with San Joaquin County <br /> ordinances, st laws, and rules and regulations of the San Joaquin Local He District. <br /> 1 <br /> APPLICANT'S SIGNATURE -_ Title r `t Date 1% <br /> FOR DEPARTMENT USE O Y <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT C1 PER SITE El EACH El January Re ed By Janu y 3i July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMIT NCE OUNT DUE CHECKED <br /> 2 DATE DA REMITTE n AMOUNT <br /> FEE 3-5� AA. tviSt�Ea 1/4/90 <br /> 90 -- �` �!✓ <br /> LESS <br /> PRORATIONPLUS <br /> ��ryry �A WILL <br /> PENALTY 111"MALII S V'4�IL I 1 <br /> OTHERY-5 F50M BILLING DATE, <br /> OTHER <br /> D-7-S <br /> Received by Date �Pt No. Permit No. ISS ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Bax 2009 STOCKTON,CA 95201 v <br />