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Applications Will Be Procr ?d When Submitted Properly Completed. Be Surr -1 Sign The Application. <br /> APPLICATION w <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.MOUSING <br /> ENGINEER'S AN IF VEHICLE INVOLVED,GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. <br /> WrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> 4 STRRATION,y G MnL�/ MISCELLANEOUS SERVICES Regist. No. <br /> �E =H' V-�-IDVL7 Color <br /> -Application Date tg I71��1 Business/Name To Appear On Permi F �N& Ir�,iP( I/ 1 <br /> FType Permit/Service Requestad:efllL \IAPDK Peng S11RV PUI K <br /> QApplicant Name ���l�hl iiI t4 IEN "(Fdi► b�Ol1Y Addr as (�1 C F <br /> Business Telephone o 1u)5�lgs 1D I 1 <br /> u Emergency Telephone NOT Z- 3 <br /> `a Property Location/Address 'rRAITINA AAD '9Wr-(DM CA <br /> Property Owner rev 5 Address <br /> NENRY \/W wyj <br /> LOperator's Name Address 1E <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 Supply Source Animal Waste Disposal Method <br /> 8. ❑ CONSULTATION FEE <br /> >4JWPLAN CHECKING FEE ,iis4g��—�L9 <br /> 8. REAL ESTATE 1/ v <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 out n/d)/r)ed let'ons of the San Joaquin Local Health District. 1,�/ <br /> APPLICANT'S SIGNATURE X ��✓w'• O Title Cd�Yp NJ I/w�_ Date Z _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 S Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> Recd by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 19111 E.H"ELTON AVE.,P.O.Boa 2909 STOCKTON.CA 96201 <br />