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Applications Will Bei When Submitted Properly Completed. Be .P Sign The Application. <br /> .+/ APPLICATION owe./ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEERS AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> IrENSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. .BER — —. n Color <br /> f Application Date �• ) O 1 R � V Bus! ess/Name To Appear On Permit LALI f7• S�l^9 QQ'9 <br /> `I Type Permit/Ser Requested: — v_. Iry <br /> Applicant Name /-k(�� (�'rvll L-M).j , LMC Address 4a1 W< UA--r-clla 0 rb <br /> —_ Business Telephone No. Em rg ncy Telephone No.-T-?D-5/, 32 <br /> ,��-T,l �A J T 127 RASA �Xl GfGr�� s� <br /> IL Property Location/Address__7vSar <br /> Z Property Owner_�+��'11�3"aD�-t:.�'Cn_�. L-r--b W _ _ ____ Address 10 I O <br /> Operator's Name ZY ,. �a�\�J'V7 Address O I� <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 <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 BATHI 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 /> Water Supply Source _... Animal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE pp <br /> 7. P-PLAN CHECKING FEE le 4 P' A/I FAA <br /> B. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 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 la rules and regu tions o the San Joaquin Local Health District. p I, <br /> APPLICANT'S SIGNATURE 1fiAJ Title 7. O 1✓K.J - Date <br /> FOR DEPApTMENT USE ONLY <br /> Fee 19 Due: 11 ANNUALLY [I PER UNIT ❑ PER SITE EACH ❑ January 1 S Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ft AMOUNT <br /> PEE 3S.ob 4� / "' 01, kfF <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received bj Date %,,eceipt No. Permit No. I•`�II/tee Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.be 2009 STOCKTON,CA 95201 <br />