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Applications Will Be Pr*sed When Submitted Properly Completed. Be *o Sign The Appllcation. <br />APPLICATION <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />tNGINFER'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 />SBOXER AND/OR ILEAL ESTATE INSPECTIONS Lia. No. <br />,ir.FNSE AND/OR POULTRY RANCHES AHO KENNELS Regist. No. <br />3TRATION MISCELLANEOUS SERVICES <br />I SEA Color <br />[Application Gate Business/Name To Appear On Permit— <br />Type Permit/Servlce Requested: <br />Applicant Name SIA Address 2 000 w T om' <br />Business Telephone NO. Emergency Telephone No. <br />Property LocatlOn/Address <br />A- <br />4PropertyOwner Address <br />-(,Operator's Nerfle Address <br />f. FOOD ESTAOLISHMENTS Total Building Sq. Footage Restaurant, Maximum Sealing Capacity <br />0 RESTAURANT 13 FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />E3 FOOD PRbMSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br />0 ROADSIDE FOOD STAND E3LIQUOR STORE ❑ BAR ❑ITINERANT RESTAURANT <br />0 CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />0 VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />FOOL) rROO HARIVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />11: HOUSING'' <br />d HOTEL/MOTEUNo. of Units ❑ CERTIFICATE OF OCCUPANCY <br />0 MOBILE HOME PARK/No..of Spaces <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />0 PUBLIC WAi`0 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 />!i. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />r :ENNEURunwkya /Animal Population No. No. of Confining Cages <br />Sewage Dispo§al Method - <br />Solid Waste Disposal Method <br />Water Supply Source Animal Waste Disposal Method <br />S. ❑ CONSULTATION FEE <br />r-, <br />r. u rLnN <br />fl. REAL ESTATE <br />REQUEST: Water Well Inspection 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 Is and rules and.regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X'Title Date <br />FOR DEPARTMENT USE ONLY <br />17"1 rani n i-- t A Rereived Rv January 31 ❑ Juiy i t Received By July 31 <br />W. rs v— <br />REMIT <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />BASE <br />EXPLANATION <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />[5 <br />`4J <br />t-F�-LESS <br />,rte �U <br />PRORATION <br />S <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Data Receipt No. Permit No. <br />APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERM ITISERVICES <br />Issuance Date Mailed Delivered <br />1601 E. HA2ELTON AVE., P.O. Bos 2069 STOCKTON, CA <br />