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} <br /> Appllrations Will Be Pr ed When Submitted Properly Completed. Be S o Sign The Application. <br /> 40 APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make - <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Llc No . - - --- - <br /> IrENSE ARID/OR POULTRY RANCHES AND KENNELS Regist No. <br /> 3TRATIONMISCELLANEOUS SERVICES <br /> I. .dER .- P i_1T Vo Color - - - -- - <br /> [Application Date Business/Name To Appear On Permit <br /> rnType Permit/Service Requested:— <br /> iAPplic nt ame DAI 14 12.,!`411 Address � � <br /> _ e No. Emergency Telephone No. <br /> aProperty Location/Address L / <br /> 4 Property Owner— �w`^ f �� Addressic�! <br /> Add <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 /> 11HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY r f Al <br /> 1j� <br /> ❑ MOBILE HOME PARK/No. of Spaces �`' I Y <br /> 3. WATER OUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> 13 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 iv`� 'I <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds - f�U 11 1 <br /> .ENNEL/Runways /Animal Population No. _ No. of Confining Cages <br /> Sewage Disposal Method `NV <br /> Solid Waste Disposal Method — <br /> Water S te D <br /> ly Source nimal Wasisposal M <br /> —7 <br /> 6. CONSULTATION FEE <br /> 7, ❑ PLAN CHECKING FEE "0 � <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ any - <br /> Sewage <br /> e No <br /> O � <br /> Sewage System Inspection ❑ _ ---- <br /> Escrow No. — I <br /> Seller _ Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date --- <br /> I hereby certify that I have prepared thi aand that the t� cdaaeQ-wk San Joaquin County <br /> ordinances, state laws, and rules and reg aRt, 1&e an oa uin L <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 Judy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> G I, DATE DATE REMITTED AMOUNT_ <br /> FEE $105.QO 3 hrs. 2/12/90 $105.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PENALT ES WILL BEA PLIED TO PAT DUE ACC LINTS 30 <br /> OTHER DAYS FROM BILLING DATE. <br /> OTHER <br /> Received by Date Receipt No, Permit No Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Sax 2409 STOCKTON,CA 95201 <br />