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Applications Will Be Pr stied When Submitted Properly Completed. Be S To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS. HOUSING Make —_- <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. — <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS Regist. No <br /> STRATION MISCELLANEOUS SERVICE <br /> I, .dER __—_. - _--—Q Color <br /> Application Date_ a l-9�`-' Business/Name To Appear On Permit <br /> w Type Permit/ServicerRReeques ed: <br /> 1 .� <br /> Applicant Name u` 6MIN�1' <br /> _/D l P(o Address l-k LA-"LeEM Ct <br /> UIFt!(G�CrE--9A-1 A�q.- - _;r• Business Te�ephone No. _ Emergency Telephone No. <br /> iProperty Location/Address � z1- OrNa�l�l❑` V� <br /> d Property Owner of& W U _._ Address 5:59-1`116 <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 ❑ VENDIISAJ' CLE <br /> 11 FOOD CROP HARVESTING/No. of Field Employees �� 1' <br /> ALL APPLICANTS: Total Employees Including Operators _ R�Cle�ED <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OC�6fUVpViA CY z8 1988 <br /> ❑ MOBILE HOME PARK/No. of Spaces "N, <br /> 3. WATER DUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL PER4;; <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER 'e1'UTISISQj �(Ty <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 Supply Source A imal Waste Disposal Method <br /> 8. CONSULTATION FEE GST �-� IA <br /> S L-13'F7�9 LT'Bf_I L)(° I <br /> 7. PLAN CHECKING FEE <br /> 8. 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 <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 /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> AMOUNT DUE CHECKED <br /> FEE <br /> K <br /> . . - _, - l� moi DLE ACC VTJ <br /> ' J 1.LESS DAYS [PRORATION VV <br /> PLUS <br /> PENALTY <br /> OTHER n M <br /> OTHER <br /> R Ived by Date eipl No. Perms No. Iss�J Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bea 2009 STOCKTON.CA K20 <br />