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Application$Will Be PI',.Ased When Submitted Properly Completed. Be S To Sign The Application. <br /> APPLICATION <br /> - ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS. HOUSING Make — <br /> APPLICANT'S AND/OR PUBLIC POOLS,WATER SAMPLING Lic. No. <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regisl. No. <br /> irPNSE ANO/OR MISCELLANEOUS SERVICES <br /> 3TRATION Color <br /> I. .aER _--.-- --- <br /> f Application Datei-i�-a9 Business/Name To Appear On Permit-- ----- <br /> oType Permit/ServiceFequested: �I_ n- yFrT7c Pte. ,� <br /> i Applicant Name -�1+y-v Lam' — �' — Address___ [T <br /> g-1 "[fes (.f{ 9�`� -,� Bu--mass Telephone No. Emergency Telephone No. <br /> J _�_/I LC3_� --t/st�T • CTl�/'!J']7PA <br /> &,Property Location/Address <br /> i Property Owner �T f.A,. _- Address <br /> -i 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 ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/NO.of Units <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 /> 5. 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 /> Animal Waste Disposal Method <br /> Water Supply Source __ <br /> 5, gCONSULTATION FEE <br /> T. PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company .— _ <br /> Sewage System Inspection <br /> ❑ Address Tele. NO. <br /> Escrow No. <br /> Seller - -- Seller Address <br /> Telephone No.— Seller Agent Name <br /> Service Request For Date <br /> ation and that the work <br /> I hereby certify, that at I and rules and this <br /> is tolnsof the Sen Joaquin Local Health accordance with San Joaquin County <br /> sta <br /> H elth District. <br /> I APPLICANT'S SIGNATURE X <br /> Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee If Due: ANNUALLY [I PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received BY January 31 C] July 1 f Receiv REMITal By uIY 71 <br /> BASE EXPLANATION BILLING REMITTANCE REMOTE <br /> AMOUNT DUE CHECKED <br /> — <br /> DATE DATE IT77T��EAMOUNT <br /> D�� <br /> UV <br /> FEE <br /> LESS I- -NAI F . I Rf- <br /> p <br /> PRORATION r <br /> PLUS DAYS FROI I BILLING L) <br /> PENALTY <br /> OTHER <br /> 4 _ 3' <br /> OTHER —VI1IC' <br /> Recene0 Dy Dateceipt No. Permit No. Issuifse Dare Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.P.O soa 2009 STOCKTON,CA 95201— <br />