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Applications Will Bead When Submitted Properly Completed. Be o 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 AND/OR PUBLIC POOLS.WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lia. No. -- - — <br /> irENSE AND/OR POULTRY RANCHES AND KENNELS Regist. NO.- <br /> 3TRATION. MISCELLANEOUS SERVICES g <br /> I. .SER _- —_./_Q_ Color -- — <br /> [Application Date I.CL Business/Name To Appear On Permit -..-- <br /> oType Perm t/Servicq,Reques <br /> ted: -- — <br /> `ApCpl�icant 1N�ame, w am U&LCr,G(JBR-KS Address 23 411 l�'�a S I <br /> �14Jf.K�4ON _95zma Business Telephone No. - Emergency Telephone No. <br /> 6 <br /> `Property Location/Address- RIF.' 134C_o_,_Cai++er, Stockton _ <br /> aProperty Owner— _ Address — <br /> 10perator'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 Operators2. - <br /> G <br /> ❑ <br /> HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY R� q till <br /> ❑ MOBILE HOME PARK/No. of Spaces3. WATER QUALITY OV 1 0SAMPLE � <br /> C1PUBL C WATER SYSTEM❑ WATER <br /> ❑ SURFACE WATER aSUPPLY❑ CHEMICAL <br /> WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE Q <br /> S. 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 It~ 6k6LFUU42 �Lx9t=i'TTA _._-- <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 1 8 Received By January 31 ❑ July i A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE E AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3!j, $is on <br /> LESS <br /> PRORATION <br /> PLUS p P LED TO PAS DUE ACCO NTS 30 <br /> PENALTY _ <br /> t <br /> OTHER <br /> OTHER <br /> Received Dy Date ceipt No. Permit No. Issu a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE..P.O.Box]009 STOCKTON.CA 55201 <br />