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Applications Will Be Pro +d When Submitted Properly Completed. Be Su. Sign The Application. <br /> v.1x� APPLICATION �✓ <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEEPp AND/OR IF VEHICLE INVOLVED,GIVE <br /> APPLICANT'S AND/OR F000 ESTABLISHMENTS,HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> Ir'FNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No. <br /> 3TRATION MISCELLANEOUS SERVICES <br /> (Application Date J_Z � Business/Name To Appear On Permit <br /> ,aType Permit/Service Requested: __ n' _--- .---- - ----- --_--_-E2--- - A <br /> `Ap licant Name _ .� ��tC- 1`��L11-�L Address_-_ _C� <br /> unen <br /> CL- {1ASAL�I D _"1-!/!per _ Business Telephone No. _ Emergency Telephone No. <br /> Property Location/Address _-25v! ►461L� __ —__—_--- -- <br /> a Property Owner G{:taC[L&--1�� __ Address <br /> L 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 \ <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 /> 6. 6 CONSULTATION FEE U 46 LS J;6-jLG-0- <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 /> Seiler ..___—___ Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Date <br /> 1 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 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED OUNT DUE CHECKED <br /> 1- AMOUNT <br /> FEE PFNALTT t.��lll_!.. f::r ,'.(��( tr-al T <br /> LESS S I"iCLJi:I jai LLII\,. L. <br /> ^ <br /> PRORATION - ` <br /> PLUS' — <br /> PENALTY <br /> OTHER -_ Z� hV- L• O 3/2/89 <br /> OTHER zz 5D <br /> Recervei by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAiF_LTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />