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r Y <br /> • App a na Will Be Pr Old When Submitted Properly Completed. Be SE� <br /> Sign The Application. <br /> APPLICATION <br /> ENGINEER'S AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR FOOD ESTABLISHMENTS. HOUSING j `vqp'ist. <br /> HICLE INVOLVED, GIVE <br /> BROKER AND/OR PUBLIC POOLS. WATER SAMPLING 1 <br /> IrFNSE AND/OR REAL ESTATE INSPECTIONS ------ <br /> 3TRATION POULTRY RANCHES AND KENNELS <br /> I. .aER MISCELLANEOUS SERVICES .or _ <br /> [Application Date // I I�Q usiness/Name To A <br /> w Type Permit/Service equ sted:_ 1 P�e�ar OnPermit <br /> �APPlicant Na ��M�f�� /Qi� rJ- -E[Yt�i-��_(a'5_n�s_S <br /> C1� ,SS Address <br /> Busi ss Telephone No. 0 1 <br /> `Property Location/Atl ass_ -� yeaQ�/ _pr r�r Emergency Telephone No. <br /> `Property Owner (��, D <br /> -L Operators Name - -- Address j"O. Asp <br /> 1. FORD ESTABLISHMENTS <br /> Address <br /> Total <br /> ootage Restaurant, <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL Building Sg0F FOOD MARKET WHOLESALE Meximu❑m Seating Capacity <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY MEAT MARKET <br /> 1:1 ROADSIDE FOOD STAND 13 LIQUOR <br /> LIQUOR STORE ❑ ICE PLANT IJBAKERY <br /> CI CONFECTIONARY <br /> CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION a ITINERANT RESTAURANT <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ FOOD VENDOR <br /> E3 FOOD CROP HARVESTING/No. of Field Employees VENDING VEHICLE <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces ❑ CERTIFICATE OF OCCUPANCY <br /> 3. WATER DUALITY ❑ 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 /> F :ENNEL/Runways _ —. /Animal Population No. <br /> Sewage Disposal Method -- No. of Confining Cages <br /> Solid Waste Disposal Method <br /> Water Supply Source _ <br /> 6. ❑ CONSULTATION FEE Animal Waste Disposal Method <br /> 7. ❑ PLAN CHECKING FEE �CM C� :r-- 5/1/90 & 5/2/90 <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample 11 <br /> Title Company <br /> Sewage System Inspection ❑ Address ---�- <br /> Escrow No. _ Tele. 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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X <br /> Title_. Date _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 A Received By July 31, <br /> BASE E%PLANA ION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> FEE 35^ 5/90 AMOUNT— <br /> LESS <br /> MOUNT <br /> LESS 6/25/90 70 -- — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER S30 <br /> ILL APAPP ED - <br /> OTHER DAYS FRO B - - - <br /> R t ed by DOIe <br /> Receipt Na �. -- <br /> P Permit No. IsSu.nce Date— <br /> APPLICANT—RETURN Ma,leO Delivered <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E HAZELTON AVE.,P.O,cor 3009 STOCKTON r•n•em— <br />