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Applications Will BeP#`ed When Submitted Properly Completed. Be ft Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEIER'S 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 /> 3TRATION MISCELLANEOUS SERVICES Regist. No. <br /> I. ,BER Color <br /> Application Date Business/Name To Appear On Permit <br /> FType Permit/Service Requested: ------ - - --- -- <br /> St. , Dakl and 94603 <br /> Applicant Name Paradi sQ Construction Address 9220 G - <br /> U - Business Telephone No. Emergency Telephone No.CIL <br /> Property Location/Address 24081 Patterson Pass, Tracy___ _ <br /> 4 Property Owner _ -- - - Address --- <br /> -[Operator'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 ___ _ P <br /> 2. HOUSING z, YMZN7` <br /> 11 HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY �L�j y�D <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> ❑ '4 g <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) CHEMICAL APR � � [IO <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER " WRO <br /> NO OF PUBLIC SERVED (Connections) _- - pp pp 4W��� af�f]'�� r <br /> 4. RECREATIONAL HEALTH 1:1 SWIMMING POOL 1) SPA ❑ WADING POOL NATURAL BATHIIv Q,`,` <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways ._ - /Animal Population No. _ — No. of Confining Cages _ <br /> Sewage Disposai Method - <br /> Solid Waste Disposal Method --- <br /> Water <br /> —Water Supply Source Animal Waste Disposal Method <br /> 6. ®X CONSULTATION FEE Soil Sampling In-sp.- on1?�-10/�gR (tank rPmova1 ) <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 Seller Address <br /> Telephone No.-- Seller Agent Name <br /> Service Request For Date - --- -- - -- — <br /> I hereby certify that I have prepared this applicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules d r gulatio o the San Joaquin t_ocal Health District. <br /> fto <br /> APPLICANT'S SIGNATURE X Title U, Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DATE DATE REMITTED DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PENALTY $ 3.50 Penalty 413/89 38.50 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No 1Wce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 -- <br />