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` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ONVIRONMENTAL HEALTH PERMIT/SER CES <br /> ENGINEER'S AND,OR VEHICLE INVOLVED, GIVE <br /> APPL CANT'S AND!OR F000 ESTABLISHMENTS,HOUSING P Ay M E N rke <br /> CON RACTOR AND%OR PUBLIC POOLS.WATER SAMPLING �f --- <br /> BRO ER AND,OR REAL ESTATE INSPECTIONS R E C E I V EL C. No. ---- --- <br /> IREJSE AND/OR POULTRY RANCHES AND KENNELS <br /> >TRATION MISCELLANEOUS SERVICES JAN 31990 ort. No. --- <br /> BER --- -- <br /> G Job !Jo , 52-Lf'7C <br /> Application Date G Business/N me To Appear On Permit FNVAkoNMFNTAL HEALTH <br /> in Type Permit/Service e�sq/u�e�sted:--_- Cru td !yw 4 i-----10 gi s � <br /> a Applicant Name ice}&hf,4._yN 10 2 -t-J�/vlF`7. '_ M' ' �`dres2s � ,I� (.UL/l) �/ G, 1��� SLt _ <br /> S�i��71t _95-0 �usines Teeleepphone No. ��h-76� Emergency Telephone No. <br /> a Property Location/Addre6210 <br /> ss 2-7 3 SI�U.L _ 1�u- -_ __ ��� <br /> a Property Owner— M �- - dress —]. l�uf1�SyN /�/2 _ <br /> Operator's Name — 7�Y�►L Atldress — <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 APPLICANTSTotal 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 /> 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 /> Watery ply Source _ Animal Waste Disposal Method <br /> 6. d CONSULTATION FEE <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. 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 laws, and rules and regulations of the San Joaquin Local Health District. <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 July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE I DATE REMITTED AMOUNT <br /> FEE 3� _ 12-4-90 S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 1 <br /> OTHER �r l/I1 I D <br /> Ro; ; C1 p'o{� �' ^ kfED YYT'�r' DEC 7 <br /> OTHER BILUNG p P�vT DUE- EN .FFN!, 199 <br /> :. <br /> V <br /> Uvlp 1r,34 <br /> Received by Date eipt No Permit No Is Date Mailed Delivered <br /> APPLICANT—RFTtIRN ALL COPIES TO. EN NMENTAI HFALTH PERMIT-SFRVICES 1901 F H _ TON AVE P.O Roy 7,nn0 STOCKTON.CA 95901------ - <br />