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Applications Will Be 'cessed When Submitted Properly completed. Be ^ re To Sign The Application. <br /> ENGINEER'S AND/OR <br /> EN VIRONMENTAPPHEAL�THI PLICATION <br /> VICES <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR <br /> BROKER ANO/OR FOOD ESTABLISXMEHTS.MOUSING <br /> PUBLIC POOLS, WATER SAMPLING IF VEHICLE INVOLVEDGIVE <br /> , <br /> -I°E AND/OR RECEIVE <br /> Make <br /> 3TR <br /> �iRATIO REAL ESTATE INSPECTIONS <br /> —N POULTRY RANCHES AND KENNELS • E'VE. <br /> BER Lic. No. <br /> ----- MISCELLANEOUS SERVICES eGL <br /> OCT 3 oo Regist. No. <br /> [Application Date _ —Qa ��sv Color <br /> F Type Permit/Service Requested- - Business/Name To A SAN JOhQLilh <br /> �cl ppear On permit P(JgLI <br /> Applicant Name F o IRONMEN7 <br /> HLH / ` <br /> u ' Address St rl rP <br /> tProperty Location/Addr gUALCUISS Telenh, III Nen <br /> iJ Property Owner Emergency Telephone NO. <br /> Operator's Name L —�� <br /> — Address_/O rr/g__yL4 h <br /> t. FOOD ESTABLISHMENTS ToAddress —�-- <br /> ❑ RESTAURANT tal Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ FOOD PROCESSING 0 FOOD NT MARKET RETAIL ❑ FOOD MARKET WHOLESALE <br /> COMMISSARY ❑ ICE PLANT MEAT MARKET <br /> ❑ ROADSIDE FOOD STAND ❑ <br /> ❑ CONFECTIONARY STORE ❑ LIQUOR STORE ❑ BAR 11 BAKERY ' <br /> ❑ VENDING MACHINES/No. of FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ ITINERANT RESTAURANT <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees ❑ MOBILE FOOD PREP. UNIT O❑ FOOD VENDOR <br /> ^'r..D G VEHICLE fl .r- <br /> ALL APPLICANTS: Total Employees Including Operators VEN <br /> 2. HOUSING °Lo[a`c51d .•rlc <br /> r,e R.L,J✓.1.0 I K s� /LJ11 <br /> C3HOTEL/MO . Of Units ❑ <br /> 11 MOBILE HOME ME PAPARK/No. of Spaces CERTIFICATE OF OCCUPANCY <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 O SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING P CE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> F :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company — <br /> Sewage System Inspection ❑ Address <br /> Tele. No. <br /> Escrow No. - - <br /> Seller - Seller Address <br /> Telephone No. Seller Agent Name _- <br /> Service Request For Date <br /> 1 hereby certify that I have prepared this application and that the work will be done in cc rdance with San Joaquin County <br /> ordinances, state laws,and rules and regulations of the Sen Joaquin Local Health Distric . <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 8 Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> A OUNT <br /> AFEE -35% <br /> an. reA — <br /> dJ , 10 5 90 <br /> r'��C..� � uU <br /> Received by Date �,Pt NO. Permit No. IssubillI1115.1. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Sax,20" STOCKTON.CA 95201 <br />