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Applications Will Be Psed When Submitted Properly Completed. Be S To Sign The Application. <br /> e <br /> r• , f APPLICATION pC t F (D I <br /> EIY 1 C I I.L_;: W - + •� ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENGINEER'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make ---- <br /> APPLICANT'S ANCHOR PUBLIC POOLS,WATER SAMPLING <br /> CONTRACTOR AND/OR REAL ESTATE INSPECTIONS P A Y M E N T L10. No. -- <br /> BROKER AND/OR POULTRY RANCHES AND KENNELS R E C E(V E DRegist. No. <br /> InENSE AND/OR MISCELLANEOUS SERVICES <br /> 3TRATION Color <br /> I. .BER -- -_--- p FEB 1 1983 <br /> [Application Date_1a 3 -0 ,--,—c•Business/Name To Appear On Permit -- - <br /> WType Permit/Servi a Reque to :�1LLJ--.1 I <br /> `Applicant Name 0 � �- Address <br /> QQ k-�r�n�+ 9+/b D 3 8 iness Telephone No. — Emergency Telephone No. <br /> %Property Location/Address <br /> u e <br /> a• — <br /> a Property Owner Address <br /> �� I t - — <br /> lOperator's Name Address <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 13 CERTIFICATE OF OCCUPANCY <br /> ❑ HOTEL/MOTEL/No. of Units _ <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY El WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) ❑ NATURAL BATHING PLACE <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA 11 WADING POOL <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$apply Source Animal Waste Disposal Method <br /> 6. CONSULTATION FEES <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 Address <br /> Seller - <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 Hea th District. d <br /> APPLICANT'S SIGNATURE X Tit, <br /> Date 1 d <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 A ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED NT_ <br /> r r1 p <br /> FEE 3�7 � YL 1 G O9 r�17 -39-60 <br /> —. <br /> PRORATION 1-1 I` 1 I��/'O I\LESS �TTL ACCO NTS 30 - <br /> PPLUSENALTY DAYS FR IY1 Fd LUNG �'tIG. - <br /> OTHER — <br /> OTHER <br /> Recervetl by Date Receipt No Permit No ce Date Mailed Delivered <br /> LTON AVE.,P.O.Boa 20M STOCKTON,CA 96201 <br />