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_ Applications Will Be Prod When Submitted Properly Completed. Be Su0 Sign The Application. <br /> 1 APPLICATION /^ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEH �` fD, G.iE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS.HOUSING <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING _ <br /> BROKER AND/OR REAL ESTATE INSPECTIONS O. _...__.._ <br /> IrENSE AND/OR . POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES I - ----- - --- <br /> 1. dER ._ O/ <br /> f Application Date . .. I_Oh I)$b__ _ Business/Name To Appear On Permit <br /> ,Type Permit/Service Requested: <br /> �77 <br /> <Applicant Name -Gyri of�1__ ._._ _l!$L1G-I�oRKS_ Address J.'7 <br /> Business Telephone NO(64)q�?y=-3z?9_..__.. Emergency Telephone No --_ _— <br /> IProperty Locatio ddress <br /> 'Property Owner 2Y_C1F___Sf[Yic T>7n/ _ ______ Address '`424T _L�Y1�PB-�U--- --.---- _---- <br /> -[Operator's Name _.-_----___ _. _-___- _ Address -----.- <br /> 1. <br /> ddress -__— ._1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> 0 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 /> 0 HOTEL/MOTEL/No. of Units -_--- ❑ CERTIFICATE OF OCCUPANCY <br /> 0 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 KENNEL/Runways - --_-- /Animal Population No. - No. of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Anima Waste Disposal Method <br /> 6. C& CONSULTATION FEE -5011_ R T' I A/SPA!?In <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 A Received By January al ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> REMITTED <br /> VyAMOUNT <br /> FEE _ `*35' IN.: CT104-E 10/13/88 00 _- <br /> LESS <br /> PRORATION <br /> PLUS p'6,\!k W�iLpL 8E APPIE^ 0 PAST DUE ACCO Niv . 4 <br /> PENALTY <br /> OTHER IJ/%1 TT rr 11 <br /> OTHER <br /> Recurvc0 by Date Receipt No Permd No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Be.4009 STOCKTON,CA 95201 <br />