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f <br /> Applications Will BSP sed When Submitted Properly Completed. Be S� -To Sign The Application. <br /> APPLICATION M. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICESk <br /> N--iNEER'S AND/OR . <br /> APaLI�ANT•S AND/OR FOOD ESTABLISHMENTS,HOUSING IF VEHICLE INVOLVED, GIVE <br /> I Make <br /> CONTRACTOR AND/OH PUBLIC POQLS,WATER SAMPLING <br /> 70KER ANDiCR REAL ESTATE INSPECTIONS Li4i <br /> No. <br />_ SE AND/OR POULTRY RANCHES AND KENNELS ji <br /> ;TRATION MISCELLANEOUS SERVICES Regist.;No. <br /> i. BER <br /> Color {' <br /> t <br /> [Application Date G-6- g� Business/Name To Appear On Permit <br /> Type Perm it<jervice equested: 2L.*ycLsw_ or _,r='wwtctntne..rr=,o-j::nj a5,`C.- <br /> a Applicant Name { - tl Cc�- Address CA <br /> - <br /> U <br /> a _ Business Telephone No. RSS=S 7!-2,4-34, _ Em ge cy Telephone No.. <br /> OX-Property Location/Address,--7-5— "S��aL%C- 14Vc� L T— <br /> 4 A <br /> Property Owner PO-fo �ODrA -CS -Cb . Address y 94-1 D <br /> � <br /> 10perator's Name 3S?�4+J SC�LPA Address '3 s` AocCA- <br /> - <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKETj, <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> 's'❑ ROADSIDE-FOOD STAND, _ 1-1-,-LIQUOR STORE -❑ BAR:;: �- -- _�_.❑.ITINERANT,RESTAURANT__., <br /> 1:1CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD•UENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE 1 <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees i payMinNT <br /> ALL APPLICANTS: Total Employees Including Operators RECEIVED <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY!! " �I po <br /> 11MOBILE HOME PARK/No. of Spaces E l JUN 1968 <br /> 9 <br /> 3. WATER QUALITY 11 WATER SAMPLE (Bacterial) ❑ CHEMICAL E ' <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER ]ENVIRONMENTAL HEALTH , <br /> NO OF PUBLIC SERVED (Connections) { PERMITISERVICES <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> SECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds I , <br /> :ENNEL/Runways /Animal Population No. No. of Confining Cages <br /> Sewage Disposal Method II r <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method i� } <br /> 6. XCONSULTATION FEE �tiutQC,n7wfL1�1'e3+ ,_ �55Cz�s�c= � 2L+xQi <br /> , J <br /> 7. ❑ PLAN CHECKING FEE II <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection[] Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> I <br /> Escrow No. <br /> Seller—"'....-. :.._ `Seller Address ak <br /> Telephone No. Seller Agent Name II <br /> Service Request For Date <br /> ti <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. 1. - <br /> i <br /> APPUCANT'S SIGNATURE X Title CAW%Qn.y•Fw�rrwlCi f7 Dale 60-W <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ 11 REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> iI! AMOUNT <br /> FEE ! <br /> LESS2 <br /> PRORATION S' ' <br /> PLUS �! <br /> PENALTY 1 <br /> OTHER i <br /> OTHER <br /> Received by Dale Receipt No. 'Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2069 : STOCKTON,CA 05201 <br /> - - - -- - - -- - - - - -----JL - ----- .- - - - -.-- . It'. -- - -- - - <br />