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Applications Will Be fed When Submitted Properly Completed. Be 00 Sign The Application. <br /> ` APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND.,OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS,HOUSING Make _ <br /> CONTRACTOR ANDrCR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND OR REAL ESTATE INSPECTIONS LIC No. <br /> irhNSE AND/OR POULTRY RANCHES AND KENNELS Regrst. No. <br /> 3TRATfON MISCELLANEOUS SERYIC�S <br /> i. .dER Color <br /> Application Date _ _.__ ._- - ------ Business/Name To Appear On Permit <br /> .Type Permit/Service Requested: - - <br /> 4 Applicant Name -Paradise Construction _ Address. 9220 G St. , Oakland 94603 <br /> u Business Telephone No. -__ _. Emergency Telephone No. _ <br /> QProperty Location/Address .24081 Patterson. Pass-, Tracy_--__ ------ - ----- - <br /> aProperty Owner _ Address --- <br /> E Operator's Name - - --- .. - - - - Address - - - - --- -- - r <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 BATHING 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 /> S. DCONSULTATION FEE Soi Sampling Tnsn_ an 12'/30/8a--(tank— emoval 1 --- -- <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 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 i R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE T <br /> EASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> -- <br /> LESS <br /> P140RATION <br /> PLUSp erg <br /> PENALTY =__e ._$__3.� rcrJ� 3 89. -- 38.50 <br /> OTHER <br /> OTHER <br /> Received by Dale Rece.pl No Peurur No Issuance Date Mailed Delivered <br />