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} M _ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> E VIRONMENTAL HEALTH PERMIT/SERVI S <br /> ENGINEERS AND-OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND OR FOOD ESTABLISHMENT$,HOUSING Make _ — <br /> CONTRACTOR AND/OR PUBLIC POOL$.WATER SAMPLING - <br /> BROKER AND,OR REAL ESTATE INSPECTIONS LIG. No <br /> Ir'F,NSE AND,OR POULTRY RANCHES AND KENNELS Rpgist. <br /> STRATION MISCELLANEOUS SERVICES <br /> Color <br /> .dER q G <br /> Application Date .... a?T"` b I Business./Name To Appear On P rLv�NG • / �mlt � /L/_CC <br /> Type Permit/Service Requested: Glyn✓6 �h�F�� -. .S�i� U(�i/!Gs Chi 41_-UhEn(1)L _-. ---. <br /> .,Applyant Name __ 1l(N� (" GICL J I/r/� _.. AddressT -- <br /> 4&41&/.—/�2 (� (oSZ �Ysay.. . Emer y - <br /> / _....... Business Telephone No.`�<-Z___. genc Telephone No — -- <br /> jProperty ?_.tion/Address .S/t/�GC/I%.-lir/?✓/ �:__/r� r �t°,v�r /y-oLo--�3 - <br /> 4Property Ciwner-L8.r<1n /fU -.G��,�2 Address . Ze91. .W•._ C�2Gr j�.� ✓i 702 -Q AC f fnL <br /> •1 Operator's Name ._- --- ------ -- ... A.,dre$s .. --. -- - -... <br /> 1. FOOD ESTABLISHMENTS Total Building S 1, 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 /> 11 CONFECTIONARY STORE ❑ FOOD SAI VAGEP ❑ FOOD DEMONSTRATION 1:1 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 /> Z. HOUSING <br /> ❑ HOTEL/MOTEL/No.of Units -.. __- ❑ CERTIFICATE OF OCCUPANCY <br /> O MOBILE HOME PARK/No. of Spaces <br /> 3. WATER OUAI ITY ❑ 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 /> .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 /> 13. ❑ CONSULTATION FEE - <br /> I 7. ❑ PLAN CHECKING FEE —- - -- <br /> 8. REAL ESTATE - S'9114IL-3 so,,- <br /> REQUEST. <br /> D'sREQUEST. Water Well Inspection❑ Sample❑ Title Company <br /> Sewage System Inspection Cl Address __. _-Tele. No. _— <br /> Escrow No -- - <br /> Seiler _--.. -..—._ 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, /91 . _-. ---- Titley' <br /> ?�FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNIJALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja.,uary 1 R Recerveo 9y Ja11ua/y 31 ❑ July 1 G Roceweo By July 31 <br /> --- �— '- REMIT <br /> EXPLANATION I BILLING REMIT'(ANCE I $ AMOUNT DUE I CHECKED <br /> BASE <br /> - 4 BASE I - DATE <br /> -- -- DATE— R!EMITTEO AMOUNT_ <br /> FEE <br /> LESS �- <br /> PR`)RATION I <br /> PLUS <br /> NE NAI Tv <br /> OT`+ER I l <br /> Q1?IER --- --- - <br /> R?CBrvQiI Gq -- Lsa1c Re?5-01 NO --- p "/"1 rr0 Issudrn_9 Dd!a Mad.d Deu•:ered - <br /> __....._ .ar.l F 1117ILTON AVE..00.HOu 200 STOCKTON.GA•05J07 <br />