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Applications Will Be Processed When Submitted Properly Completed. Be STo Sign The Application. <br /> APPLICATION <br /> IRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR ,JAMES F. CULBER F 170N FOOD ESTABLISHMENTS,HOUSING <br /> CONTRACTOR AND/OR Genera/ Confrsafc)r PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIc. N0. <br /> .IrFNSE AND/OR 641 NORTH PACIFIC AVE. POULTRY RANCHES AND KENNELS Regist. N0. <br /> STRATION LODI, CALIF, 95242 MISCELLANEOUS SERVICES g <br /> I, .BER Color <br /> f Application Date_ y— Q,gal Busines /Name To pear On Perm't — Z-7/-;tM 7 L(i/,�'/?�, <br /> FI Type Permit/Service Requested: <br /> a Applicant Name Address - / E <br /> y <br /> i � � D Business Telephone No ✓�� Emer y Telephone No. <br /> 'a Property Location/AddressL.6Z <br /> aProperty Owner Address <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 /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY �A <br /> ❑ MOBILE HOME PARK/No. of Spaces '9 <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ASO F�L� <br /> NO. OF PUBLIC SERVED (Connections) F � <br /> 4. RECREATIONAL HEALTH 11SWIMMING POOL 11SPA 11WADING POOL IJNATURAL BAT�( �LAC� O <br /> 5. VECTOR CONTROL 11 POULTRY FARM/Maximum No.of Birds <br /> r :ENNEL/Runways /Animal Population No. No.of Confining Cages 1')/-Y<- <br /> Sewage <br /> ')9lSewage Disposal Method (� F_ <br /> Solid Waste Disposal Method l <br /> Water Supply Source Animal Waste Disposal Met c! <br /> 6. CONSULTATION FEE /�L //co12 - �/ S� 1�e' <br /> 7. ❑ PLAN CHECKING FEE <br /> B. 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 h prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws ruleZi= <br /> Joaquin Local Health District. Q y7 <br /> APPLICANT'S SIGNATIIaF�/6� Title v� �� Date / 4 ^�� <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R ved 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.Box 2009 STOCKTON,CA 95201 <br />