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ppptications Witt Orocessed When Submitted Property Completed.0ure-to Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES IF VEHICLE INVOLVED,GIVE <br /> FOOD ESTABLISHMENTS,HOUSING Make ------ <br /> ENGINEER'S ANO/OR Lic. NO. — <br /> APPUCANT'S AND/OR PUBLIC POOLS,WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS Regist. No <br /> Jr-ENSE AND/OR MISCELLANEOUS SERVICES Color <br /> STRATION PARRI29 <br /> dER <br /> 10/16/89 Business/Name To Appear On Permit - <br /> fApplication Date <br /> I,Type Permit/SetvigeA9C,gy§V8 Ons _. _.. Address_p�.Q�B —LSD <br /> <Applicant Name PP RRKIJFFII as Emergency Telephone No. — <br /> u---....I--OC-Et8f1-r-�a Business Telephone No. —' <br /> `Property Location/Address , Address <br /> i Property Owner Parri Sh & Son _ <br /> Address <br /> -Operator's Name Restaurant,Maximum Seating Capacity <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage ❑ MEAT MARKET <br /> 13 RESTAURANT E3 FOOD MARKET RETAIL 13 FOOD MARKET WHOLESALE <br /> ❑ ICE PLANT COMMISSARY ❑ BAKERY <br /> ❑ SSARY <br /> ❑ FOOD PROCESSING PLANT ❑ OMMI STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> 13 ROADSIDE FOOD STAND ❑ FOOD DEMONSTRATION 13FOOD VENDOR <br /> 13CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ MOBtLE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ VENDING MACHINES/No. Of <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. HOUSING ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units <br /> ❑ MOBILE HOME PARK/No. of Spaces 13 CHEMICAL <br /> 3. WATER QUALITY 11 WATER <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 11WATER HAULER <br /> NO. OF PUBLIC SERVED (Connectiogs) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds No.of Confining Cages <br /> r '.ENNEL/Runways /Animal Population No. <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source —_ Ani mal Waste Disposal Method <br /> 6. ❑ CONSULTATION FEE •ninspection <br /> at above location /U.G.S.T. <br /> 7. ❑ .PLAN CHECKING FEE <br /> 6. 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 A Received By January 31 ❑ July 1 AReceivendEBNtyl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE 35 00 r hour 1 h ur Sam lin, inspectio on 10/12/H $35.00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY PENALTIES ILL BE APPLI rnLiMTS 30 - <br /> OTHER RO 1 BILLING D 1E. <br /> OTHER -0TAL_ S35700 7d — <br /> Recened by Date •Rece.pl No y:'armd No. Once Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEMI.' y rFS 1601 E.HAZELTON AVE.,P.O.Bov Well STOCKTON,CA 55201— <br /> A <br />