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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> EvoINFrq S AND OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANTS.AND."-OR FOOD ESTABLISHMENTS.HORSING Make <br /> ;.ONTRACTOR ANDIOR PUBLIC POOLS.WATER SAMPLING ------ <br /> 9ROKEH AND,OR REAL ESTATE INSPECTIONS Lic. No. <br /> ,rFNSF AND/OR POULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Regist. No.__... <br /> - —__-_ Color <br /> LdrJ C ir.)G'r" <br /> Appllcatipn pate ._ �"�f �T Business/Name To Appear On Permit <br /> ,Type Permit/Service Requested- <br /> Applicant <br /> equested Applicant Name ._ rs).�/ L( _�- - -- Address <br /> --....---- -.._._____w.._.. __ Business Telephone No./r/r.a- `�'"" Emergen�y Telephones. . <br /> zProperty Location/Address � .._,.......+.?.......e. <br /> - <br /> Property OwnerT_ Address <br /> a <br /> Operator's Name . .__ fr? _.__. 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 /> r❑ VENDING MACHINES/No. of __Y ._-- ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees _ <br /> ALL APPLICANTS: Total Employees Including Operators_ :: rrJ�t t PAY M E iia t <br /> 2. MOUSING <br /> ❑ HOTEL/MOTEL./No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> MOBILE HOME PARK/No. of Spaces ._......_.... <br /> _..._.__. <br /> 3. WATER QUALITY ❑ WATER SAMPLE {Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY © WATER HAULER INV)RONMFIIIV' .>,NO OF OF PUBLIC SERVED (Connections) _. PE['o z I; .,- <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No, of Birds <br /> F :ENNEL/Runways ____.__ /Animal Population No. No. of Confining Cages _ <br /> Sewage Disposal Method_ <br /> Sotid Waste Disposal Method <br /> Water Supply Source r '>• :' :.°_ Animal Waste Disposal Method — - <br /> 6. ❑ CONSULTATION FEE •� .�': ? l ,a-9Z/ <br /> 7. ❑ PLAN CHECKING FEE = — ice �•_ "r <br /> B. 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 Sarpr�Joaquin Local I Iealth District, <br /> APPLICANT'S SIGNATURE X �'�" `' fes' u�uv1 K-- -?C:.il1. - .��' q10 <br /> �" Title �✓ Date <br /> FOR=ARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 © July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FFF- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7/ <br /> Received 4y Date Receipt No Permit No " '- 'ISgu aye Mailed peliveretl <br /> �—^^� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERINITI'SERVICES i60ti.� AZELT f AYE..A.D.Sox 20Q9 STDCKTDN,CA 95201 <br />