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"Applications Will Be Pffsed When Su APPLProperly ICATION plated. Belo Sign The Application. <br /> F, ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND%OR <br /> FOOD ESTABLISHMENTS,HOUSING Make -- -' <br /> APPLICANT'S ANO/OP PUBLIC POOLS,WATER SAMPLING Li C. N0. ----- — <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Reg St. No._------ <br /> irENSE AND/OR MISCELLANEOUS SERVICES Color .= <br /> 3TRATION <br /> I. .BER <br /> Application Date Business/Name To Appear On ,Permit ----- ---— -- <br /> J___i_ Address <br /> tL I Yrl,o S <br /> Type Permit/Service I <br /> Requested i�� ����;/�/ = <br /> /! Emergency Telephone No. <br /> aApplicant Name - _ — <br /> O ��ji2U l2— Business Telephone No.— <br /> _ <br /> a — 14 <br /> aProperty Location/Address- RF _ Address — <br /> r aProperty Owner — Address — <br /> �Operator's Name -----Total Building Sq. Footage Restaurant, <br /> 1. FOOD ESTABLISHMENTS Maximum Seating Capacity <br /> ❑ FOOD MARKET WHOLESALE [I MEAT MARKET , <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ ICE PLANT 1:1 BAKERY <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ BAR ❑ ITINERANT RESTAURANT <br /> 11 ROADSIDE FOOD STAND ❑ LIQUOR STORE 11 FOOD VENDOR <br /> ❑ CONFECTIONARY STORE 11FOOD SALVAGER 13 FOOD DEMONSTRATION ❑ VENDING VEHICLE <br /> ❑ MOBILE FOOD PREP. UNIT <br /> ❑ VENDING MACHINES/No. Of _ <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees --- <br /> ALL <br /> —ALL APPLICANTS: Total Employees Including Operators---- <br /> 2. <br /> --2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. oWATER SAMPLE (Bacterial) 13 CHEMICAL <br /> ❑ •, <br /> 3. WATER QUALITY 13WATER HAULER " <br /> ❑ PUBLIC WATER SYSTEM 11 'SURFACE WATER SUPPLY <br /> NO. OF PUBLIC SERVED (Connections) ❑ SPA ❑ WADING POOL 13 NATURAL BATHING PLACE <br /> q. RECREATIONAL HEALTH ❑ SWIMMING POOL <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> -- -- — <br /> /Animal Population No. — No. of Confining Cages <br /> F '.ENNEL/RLLMOYS <br /> Sewage Disposal Method ------ <br /> Solid Waste Disposal Method — --— ---- Animal Waste Disposal Method <br /> Water Supply Source ------ r_rCAJ ` <br /> I'll 11. '!.i/• <br /> 6. wcf CONSULTATION FEE =-- <br /> 7. ❑ PLAN CHECKING FEE -- <br /> B, REAL ESTATE Title Company — - <br /> REQUEST Water Well Inspecticm❑ Sample❑ Tele. No. <br /> Sewage System Inspection <br /> ❑ Address — <br /> Escrow No. — --- ----- - <br /> Seller Address <br /> Seller _—-.-- ----- — <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, and rules and regulations of the San Joaquin Local Health District. <br /> Title Date <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 31 <br /> REMIT <br /> FFE <br /> ue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH REMITTANCE <br /> t A Received By January 3LAMD❑TJDUE uly 1 a ReceiCHECKEDved By y <br /> BILLING DATE REMITTED AMOUNT_ <br /> B <br /> ASE EXPLANATION DATE <br /> HIL <br /> °35.20 <br /> — <br /> o�1 <br /> Y� t <br /> Permll No. isWe Date Mailed Delivered <br /> Date ceipt No. <br /> 95201- <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 3009 STOCKTON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />