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Applications Will Be c ssed When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION -wool <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND,OR V ICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR - - _ FOOD ESTABLISHMENTS.HOUSING a <br /> CONTRACTOR AND/OR `.,.�,. ,__a PUBLIC POOLS, WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS iC. N0. ---.--- <br /> InFNSE AND/OR POULTRY RANCHES AND KENNELS Regist No._ <br /> STRATION ULU 19 1990 MISCELLANEOUS SERVICES --"- <br /> I. .8ER _—___. _._ Color ---_ <br /> p�J�,/IRONMENT �16c/est= Ta Itow Cc, <br /> Application Date_���_�"_ i s e To Appear On Permit __ - _. <br /> MType Permit/Ser Re <br /> wasted: s-. - fogj'l�'—___-- --- <br /> iApplicant Name - re"t 7-e:l.wrct _— —. Address-X4QllRlr/M <br /> &f4 Business Telephone No. 2M- 538 _6Y$1. Emergency Telephone No. <br /> '<Property Location/Add--rrJe — <br /> --- <br /> �PropertyOwner_ -.--1 ____ _. __-.._ __._ Address _ ('iwaas � � � �•Z4 95353 <br /> [Operator's Name - Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOQ MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT \i,❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND t+ 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 Fie Employees <br /> ALL APPLICANTS: Total Employees Inclu 'ng Operators---- <br /> 2. <br /> perators <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 (B cterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WA ER 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/Maxim No. of Birds — <br /> r :ENNEL/Runways /Animal Population N No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water pply Source --_ Animal Waste Disposal Method <br /> 6. W CONSULTATION FEE <br /> 7. ❑ .PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Semple❑ Title Comp y __. <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 'll be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local ealth 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 A Re wed By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION DATE DATE REM'E1TED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> v <br /> OTHER <br /> OTHER <br /> Received by Date jI _iipt No. Permit No. Issuti.00bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11101 E.HAZELTON AVE.,P.O.Boa 211010 STOCKTON,CA 55201 <br />