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Applications'Will Be P, 1 When Submitted Properly Completed. Be e - Sign The Application. <br /> -- APPLICATION <br /> "ENGINEER'S AND/OR <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES APOLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR MEAL ESTATE U INSPECTIONS /��� AjC. st. <br /> J CENSE AND/OR POULTRY RANCHES AND KENNELS �J.1, <br /> STRATTON MISCELLANEOUS SERVICES egist. NO. <br /> 1. .aER _ Color <br /> 4f Irr f Application Date Business/Name To Appear On Permit <br /> *Type Permit/Service Requested, <br /> Applicant Nam L4T; <br /> Icb <br /> N Ahone No. Emer encyTProperty Location/Addr s (Y' .�Property Owner Address <br /> Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ 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 /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways /Animal Population No. No,of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water upply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEE _1�S ,QYII/(r Sol' SLtihw.x�Ly�e7 /.IiI...T.[QiY <br /> 7. ❑ PLAN CHECKING FEF <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name aYM +��, <br /> Service Request For Date ECSl�-- <br /> I hereby certify that I have prepared this application and that the work will be glgeer,ln$ccordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Locall.Healt�/ I 9 1988 <br /> APPLICANT'S SIGNATURE X Tit VVIR Date <br /> FOR DEPARTMENT USE ONLY PAIIIISERVICE <br /> Litif <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 /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DA E DATE REMITTED AMOUNT DUE CHECKED <br /> /' �] AMOUNT <br /> FEE 4v / Z <br /> LESS o <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER IDAYS FROM BILLING U J `r N I i 15V <br /> kTE <br /> OTHER <br /> Re4by Dale ipt No. Permit No. tae Date Melted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo[2009 STOCKTON,CA 95201 <br />