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--•�..__.._..- ..... -- • •___...- ...,... -........... .,..w..r ..r.,.,Pwled. Ba Sure TO Sign The APPlldttlon. <br /> APPLICATION <br /> ENGINEERS 4Np'OR ENVIRONMENTAL HEALTH PERMIT/S niICES <br /> APPLICANT'S AND,OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> CONTRACTOR AND/OR PUBLIC POOLS.WATER SAMPLING Make <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Li C. N0. . <br /> IIENSE ANO.OP POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regal. NO.. . <br /> aER __ Color <br /> 'Application Data. - 3 " Y'� <br /> Business/Name To Appear On Permit <br /> yl Typo Permit/Service equestetl:. Soi' �ori:r. �tr,r'Cl�FicAv/✓<tJ — <br /> i li <br /> Appcant NameJf _E.w.:b,r.,r.r�,r. .+/ ,rAW:f.,...yf •T_.. --Tr' <br /> � .._ Atltlress �/�ar.P.ri �,,,r s4ie C' of.•fi</eeAy_ Tf�g <br /> Business Tele none yp �9�, PBZ-alio .. Emergency Telephone No« 9LQ- <br /> Property Locauon/Atloress _22�._4�`^✓ww ';. / 7 s cf� <br /> Property Owner .SXil/ e.Y l�o,.�,r,P y.rJ,/.fox FoL3 - a...d Cq <br /> t "1 _ Address 9ysr y <br /> !Operator's Name —.. .. y 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 ❑ LIOUOR 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 /> T. 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 /> NC. OF PUBLIC SERVED (Connections) <br /> d- RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA 13 WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways . ._..-- /Animal Population No. ...� No. of Confining Cages <br /> Sewage Disposal Metnotl <br /> Sold Waste Disposal Method <br /> Water Supply Source _..._ Animal Waste isposal Met od _ <br /> tit CONSULTATION FEE Sot ri:HJ wr.AN �,e iew, ��/� <br /> 7. ❑ PLAN CHECKING FEE <br /> 6. REAL ESTATE <br /> REQUEST: Water Well InSpectlonO 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 reguiations of the Sen Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ._, Title <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Out: ❑ ANNUALLY ❑ PCR UNIT ❑ PER SITE ❑ EACH ❑ January I d Rece"d By January sl ❑ July I A Rat«.ad By Jul,31 <br /> " REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTEd AMOUNT <br /> FEE J .i .� <br /> LESS. "' <br /> PRORATION_ <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> 01HER <br /> RlOelreo uy Dale R!0l121 No PBrmll 140. <br /> IasuanCa Dale MMNd DelrWrtd <br /> APPUCANT_RETURN ALL COPIES TO: ENVIRONMENTAL WEALTH PERMIT/SERVICES 101 E.NA>:ELTON AVE..P.C.Bea 2009 STOCXTON.CA H2O1 <br />